Final Report - UNESCO · Greenall, Mr. Tom Mogeni, Mr. James Humuza, Mr. Néhemie Nkunda Batware,...

Joint Review Final Report

National Multi-sectoral Strategic Plan on HIV and AIdS 2005-2009

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Contents

7 Acknowledgements

9 Executive Summary

13 Acronyms

15 1. Information about the Joint Review

17 2. Methodology of Joint Review

21 3. Joint Review Findings: HIV Service Delivery

65 4. Joint Review Findings: Cross-Cutting Issues

75 Tables

93 References

97 Annex 1: Key questions

109 Annex 2: Districts, Focus Ggroup Discussions, and Other Relevant Activities Conducted in Each District

113 Annex 3: Focus Group Data Collection Tool

117 Annex 4: National Level Key Informants Data Collection Guide

119 Annex 5: District Level Key Informants Interview Guide

121 Annex 6: District Implementers’ Meeting Agenda

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ACKnowLeDGeMentS

The National AIDS Control Commission (CNLS) would like to take this occasion to express its deep ap-preciation and sincere thanks to all who participated in this joint review, especially the national and inter-national institutions who contributed technical and financial support including advice, consultation and participation in numerous meetings and workshops. The national partners who deserve special thanks in-clude TRAC Plus, the Ministry of Health, the Ministry of Gender and Family Promotion, representatives from all national umbrella organizations and district partners.

We would particularly like to thank the members of the Planning, Monitoring and Evaluation Technical Work-ing Group (TWG) who served as the Joint Review Steering Committee and guided the review from devel-opment through implementation. Notably, Ms. Amina Rwakunda, Mr. Gakunzi Sebaziga and Mr. Pierre Dongier from CNLS, Ms. Doris Mukandori from TRAC Plus, Ms. Elisabetta Pegurri from UNAIDS, and Mr. Andrew Koleros from MEASURE Evaluation.

This review was conducted through a team of dedicated international and national consultants who significantly contributed to the development of a comprehensive and participatory methodology and worked tirelessly to ensure high quality data collection, analysis, and concrete recommendations for the development of the new National Strategic Plan. Special thanks go out to our consultant team: Mr. Michel Carael, Mr. Matthew Greenall, Mr. Tom Mogeni, Mr. James Humuza, Mr. Néhemie Nkunda Batware, Mr. Justin Ngendahayo, and Mr. Stanis Ngarukiye.

In addition, a special acknowledgement is due to all na-tional and international stakeholders who participated in the field visits and conducted primary data collection with HIV program beneficiaries. Your dedication to collecting quality data to inform this review is greatly appreciated and facilitated the production of a compre-hensive final report.

— Dr. Anita AsiimweExecutive Secretary, CNLS

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eXeCUtive SUMMARY

The joint review of the National Strategic Plan (NSP) on HIV/AIDS 2005-2009 was carried out between August-November 2008. The overall goal of the joint review was to assess progress and achievements of the NSP 2005-2009 as well as to make recommendations to reinforce measures for a sustainable multi-sectoral response to HIV/AIDS across the country.

The review was carried out under the leadership of the CNLS, and it involved stakeholders from all sectors in the collection and the analysis of data. Using routine data, program reports, discussions with program imple-menters and with program beneficiaries themselves, the review examined the following areas:

• Progress in implementing the NSP 2005-2009.• Relevance of the response to the HIV epidemic

and relevance and effectiveness of interventions.• Gaps and areas not adequately addressed, and

solutions to remedy these gaps in the forthcoming plan.

AXiS i: ReinfoRCe MeASUReS of pReventinG Hiv/AiDS tRAnSMiSSionKey achievements and gaps were as follows:

• None of the available data showed strong evidence of increases in HIV prevalence at a national level over the period 2006-2008; however nor do they provide any evidence for decreases in HIV prevalence.

• In terms of behavioral change, data showed both positive and negative changes, with some sources reporting increases in rates of systematic condom use and others indicating an increase in the percentage of young people with more than one sex partner.

• A large proportion of the population was reached by basic HIV/AIDS information and HIV testing.

• Access to condoms, HIV testing, and STI treatment was uneven, with some of the most at risk populations reporting low levels of access.

• On the whole programs failed to systematically target the most at risk groups or the defined “hotspots”. This was partly because understanding of the epidemic has evolved since the NSP 2005-2009 was written, but also probably because of barriers to working in some hard-to-reach or

marginalized contexts.• Different components of HIV prevention are

often implemented in a fragmented way, meaning that many populations are not receiving a comprehensive “package”.

Specific recommendations for HIV prevention efforts the NSP 2009-2012 included the following:

• Ensure that strategies are evidence-based.• Address the causes of stigma.• Provide HIV prevention services and

interventions as a comprehensive “package”.• Ensure continuity of HIV prevention

interventions and services.• Ensure that intensive prevention programs

primarily reach most at risk groups, while continuing to implement broader strategies for the general population.

AXiS ii: nAtionAL ReSponSe to Hiv/AiDS ADApteD to RwAnDA’S ConDitionS AnD SURveiLLAnCe ReSeARCH ReSULtSKey achievements and gaps were as follows:

• Major progress was made in developing new and different data and information dissemination mechanisms and there are several strategies now in place that did not exist in 2005. The two annual research conferences give a national platform for information dissemination and regroup all of the major HIV stakeholders to exchange results, best practices, and lessons learned. However there are still gaps in the routine analysis and dissemination of data.

• The HIV/AIDS Research Committee to assist in the coordination of national and international HIV research was developed during the review period. This mechanism to coordinate research and promote a better exchange among researchers nationally is a large achievement over the course of the plan.

• There is a general lack of strategy for building capacity in research, surveillance and data use, both for technicians and non-technicians.

• There is no mechanism in place to coordinate behavioral surveillance activities being conducted by different actors. In addition, there is no

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prioritized list of potential at-risk populations that should be tracked through surveillance.

Specific recommendations for HIV surveillance, re-search and use of data in the NSP 2009-2012 included the following:

• Develop better mechanisms for analyzing data at national level and disseminating them to districts.

• Re-evaluate behavioral surveillance activities given new data and modeling.

• Better coordination of behavioral surveillance activities.

• Review the role of the Research Committee in developing and coordinating a national research agenda with MOH, School of Public Health, TRAC+ and other research partners.

AXiS iii: iMpRove Hiv/AiDS tReAtMent, CARe AnD SUppoRt foR peRSonS infeCteD AnD AffeCteD bY Hiv/AiDSKey achievements and gaps were as follows:

• The proportion of patients in need enrolled into ARV program increased from 35% in 2005 to 76% in 2008. The number of patients lost to follow stayed about constant. Moreover there was significant reduction in the real cost of accessing ARV services by PLWHA with the introduction of Mutuelles de Santé covering for ARV treatment. Opportunistic Infection treatment was included into other services packages offered by community based health insurance. However, a significant gap was that pediatric care was not sufficiently reinforced.

• There was an increase in percentage of facilities offering ARV services from 23% to 43% (Dec 2008); however there was insufficient training for health personnel on existing guidelines in HIV/AIDS care (including pediatric care).

• There was significant improvement in the collaboration between health facility and community based agents to facilitate clients, and community-based care organizations improved HIV/AIDS service delivery compared to the 2005 situation.

Specific recommendations for care and treatment of people living with HIV included the following:

• Harmonize package and monitor the partners to implement national nutritional guidelines, adherence support, and community care and

support.• Adopt task shifting to solve problems of shortage

of human resource.• Develop a strategy to enroll and retain health

personnel in the HIV/AIDS field.• Reinforce pediatric care provision.• Develop guideline and train guidelines users,

particularly for the community based care interventions and for pediatric care.

AXiS iv: MitiGAtinG tHe SoCio-eConoMiC iMpACt DUe to Hiv/AiDSKey achievements and gaps were as follows:

• Income generation activities (IGA) funded through the micro project mechanisms of various projects (MAP, GF, CHAMP, CNLS/UNDP/ADB) have helped a large number of HIV positive member associations to initiate or strengthen collective projects that have had profound effects on their livelihoods, more so in terms of decreased stigmatization and social isolation than in terms of economic status per se. The substantial support to OVCs for access to education is also a major achievement of the last few years and will help to decrease the vulnerability of these children and youths. However, there are gaps in support for management and technical assistance to IGAs, as well as in access to credit.

• Important steps have been made in the establishment of an enabling environment for legal and policy framework for the protection of rights of people living with HIV/AIDS and OVCs and for prevention and prosecution of sexual violence. Access to numerous services for vulnerable groups has also significantly improved during this period: access to health services (Mutuelles de Santé), education, social protection and legal services through various projects. However there are also gaps. There are few workplace programs for HIV prevention and access to care and treatment for employees, lack of coordination of different services (health, social, police, legal assistance) and limited access to legal protection. Identification of OVC at district level has suffered from a lack of transparency and consistent application of criteria, meaning that support does not always reach all of those in need.

• RRP+ has considerably strengthened its coordination mechanisms during the period of the NSP with the setting up of district

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coordinators in half of the districts and the strengthening of its central staff for coordination and M&E purposes. The delegation of representation from the grassroots level to the national level ensures the participation of local communities in the planning, implementation and evaluation of activities concerning HIV/AIDS. The transformation of the associations into cooperatives is also a mechanism to ensure fuller participation of members into the decision making process of the organization: well established rules for the functioning of the cooperatives describe clearly the transparency and inclusiveness that must be respected in distribution of profits from the organization’s activities and in decisions about the management of these activities.

Specific recommendations for mitigation of the socio-economic impact of HIV included the following:

• Focus income generation on production activities that respond to the market needs and on cooperatives’ capacity building to identify and assess market opportunities.

• Clarify the regulation on formation of cooperatives in order to ensure that it responds to the vulnerable people’s needs and to support partners in their organizational capacity building and improvement of their business performances.

• Support is required to improve the dissemination of criteria for OVC identification and to increase transparency in how criteria are applied at district level. At the same time, efforts are required to scale up the numbers reached by essential support and to ensure that in each case the minimum

service package is provided. • Understanding of rights is a gap, and emphasis

should be placed on ensuring that vulnerable people know their rights. It is also important to provide legal support and to enhance the collaboration system between health service providers, local authorities and the police.

AXiS v: pLAnninG AnD CooRDinAtion of tHe ReSponSe to Hiv/AiDSSpecific recommendations on planning and coordination:

• Ensure adequate resource allocation for an effective participation of all sectors in the multi sectoral HIV response according to EDPRS, sector strategic plans and annual work plans.

• Strengthening of central structures and especially decentralized structures. Ensure sustainable mechanisms for adequate resources (human and financial) to coordinate and represent civil society organizations.

• Strengthen capacity of CDLS to coordinate all partners within the district and take an active role in fund allocation decision making.

• Develop a national capacity building plan to which all partners will contribute in a coordinated manner.

• Improve involvement of international donors and implementing NGOs in planning and coordination processes. Ensure that international partners’ interventions correspond to priorities identified at national and district level.

• Strengthen regional coordination mechanisms to harmonize cross border aspects of HIV response.

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AIDS Acquired Immune Deficiency SyndromeANC Antenatal ClinicART Anti Retroviral TherapyBCC/CCC Behavior Change Communication/Communication pour le Changement de

ComportementsBSS Behavioral Surveillance SurveyCAMERWA Centrale d’Achat des Medicaments Essentiels au RwandaCBHI Community Based Health InsuranceCDLS Comité de district de lutte contre le Sida – District AIDS CommitteeCHW Community Health WorkerCNLS Commission nationale de lutte contre le Sida – National AIDS Control CommissionDBS Dry Blood SampleDH District HospitalDHS/RDHS Demographic and Health Survey / Rwanda Demographic and Health SurveyEABC Education, Abstinence, Be faithful and Condom useEDPRS Economic Development and Poverty Reduction StrategyEGPAF Elizabeth Glazer Pediatric AIDS FoundationEPP Estimation and Projection PackageFD Fondation DamienGlobal Fund The Global Fund to Fight AIDS, Tuberculosis and MalariaHMIS Health Management Information SystemHIV Human Immunodeficiency VirusICAP International Center for AIDS Care and Treatment ProgramsIEC Information, Education, Communication KAP Knowledge, Attitudes and Practice MAP Multi-sectoral AIDS ProgramM&E Monitoring and EvaluationMoH Ministry of HealthNISR National Institute of Statistics of RwandaNLR National Reference LaboratoryNSP National Strategic PlanOI Opportunistic InfectionOVC/OEV Orphans and Vulnerable Children/Orphelins et Enfants VulnérablesPCR Polymerase Chain Reaction (Early pediatric diagnostic technique)PEP Post Exposure ProphylaxisPIH Partners in HealthPIT Provider-Initiated TestingPLWHA People Living with HIV and AIDSPMTCT Prevention of Mother to Child TransmissionPNILT Programme National Integré de Lutte contre la Lèpre et la Tuberculose

ACRonYMS

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SE-CNLS Secrétariat Exécutif de la Commission Nationale de Lutte contre le SIDA – Executive Secretariat of the National AIDS Control Commission

STI Sexually Transmitted InfectionSW Sex workerTB TuberculosisTRAC PLUS + Treatment and Research AIDS Center PlusUNAIDS The Joint United Nations Programme on HIV/AIDSUPDC Unité de Planification et Developpement des CapacitesUSG United States GovernmentVCT Voluntary Counseling and TestingWFP World Food ProgramWHO World Health Organization

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1. infoRMAtion AboUt tHe Joint Review

1.1 – Hiv/AiDS epiDeMiC in RwAnDARwanda has a generalized HIV epidemic, with an HIV prevalence of 3.0% among adults aged 15 to 49 years (4). It is estimated that about 170,000 people, including adults and children, are living with HIV (8). Massive population flows during and after the 1994 genocide have increased the urban population, and there has also been a recent acceleration of urbanization in Rwanda. HIV prevalence rates are higher in urban areas (13% in Kigali City and 5% in other urban areas) than in rural areas (2.2%). Substantial differences in prevalence were also found between men and women (2.3% among men against 3.6% among women) (4).

According to the Rwanda 2008 Epidemic Update, among adults 15+ years old, about 61,500 were in need of ART in 2008, with more than 43,000 (70%) receiv-ing treatment through September 2007. According to Spectrum estimates1, 55% of HIV-positive pregnant women received a prophylaxis regimen through Septem-ber 2007 to reduce the risk of mother-to-child transmis-sion. By December 2008, 75% of health facilities had integrated services for the prevention of mother-to-child transmission (PMTCT), and high levels of women at-tending antenatal clinic visits (ANC) in PMTCT centers were tested for HIV and knew their results. This is esti-mated to represent 66% of all pregnant women in 2008.

1.2 – oveRview of tHe nAtionAL StRAteGiC pLAn (nSp) on Hiv/AiDS 2005-12The National Strategic Plan (NSP) on HIV/AIDS 2005-9 was developed and adopted in 2005. The goal of the strategy was to reduce HIV transmission and alleviate its impact on Rwandese communities, families and people living with HIV/AIDS, and ensure their global care and treatment during the implementa-tion period. The purpose of the NSP is to provide an operational framework through which all interventions against HIV/AIDS find their contribution. The strategy has five main purposes (axes):

1. To reinforce measures of preventing HIV/AIDS transmission.

2. To assure that the national response to HIV/AIDS is adapted to Rwanda’s evolving socio-economic & health conditions by using surveillance and research results.

3. To improve HIV/AIDS-related treatment for persons infected and affected by AIDS.

4. To mitigate the socio-economic impact of HIV/AIDS.

5. To coordinate the Multi-sector response for increased cost-effectiveness.

1.3 – pURpoSe of Joint ReviewThe national HIV response in Rwanda is coordinated by the National AIDS Control Commission (CNLS), following the Three Ones principle. As such, the CNLS is coordinating the development of a new strategic plan for the period 2009-12 in order to align with the Economic Development and Poverty Reduction Strategy (EDPRS) 2008-12. In the EDPRS, HIV/AIDS is mainstreamed as a cross-cutting issue, ensur-ing all sectors define adequate responses to HIV with measurable targets for 2012. As CNLS coordinates the multi-sectoral response to HIV, it is thus necessary that CNLS also harmonizes with the implementation period put forth in the EDPRS. In order to collect a better evidence base for the development of the new plan, the CNLS decided to review the current plan and assess progress to date in achieving the stated objectives. Therefore, data collection on program indicators is a key component of this review as it will feed into the next NSP 2009-2012.

The overall goal of the review is to assess progress and achievements to date in the implementation of the NSP 2005-2009 as well as provide findings and make recommendations to strengthen a sustainable multi-sectoral response to HIV/AIDS across the country. The data presented in this report are only those which are relevant to the review of achievements in the national HIV response during the period 2006-2008. The joint review specifically focuses on the following areas:

• Progress made against planned initiatives: Outputs and Outcomes.

• Relevance and effectiveness of the interventions implemented.

• Gaps/areas not adequately addressed.1. Statistical program used to make estimates and

projections for HIV epidemic in Rwanda

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• Constraints facing the national response.• Lessons learnt.• Recommendations for the next NSP.

1.4 – GUiDinG pRinCipLeSThe review used the following guiding principles set forth in the UNAIDS guidance paper Joint reviews of the National AIDS response (2008):

• National Ownership: The review was a national exercise and the process was initiated and driven by the designated national coordinating entity CNLS.

• Relevance: The Joint Review Steering Committee (JRSC) ensured that the design, scope, and any special focus areas for the review were relevant to the status and trends of the HIV epidemic in Rwanda, and of the national response.

• Inclusive and Participatory: All relevant partners and stakeholders were part of the whole process. Particular attention was paid to securing participation of people living with HIV and of most-at-risk populations (sex workers, motorcycle and truck drivers).

• Commitment to results: Involvement in the

planning and implementation of the review also implies that participants agree to follow up on the findings and recommendations.

• Impartiality: The choice of the JRSC as well as the review methodologies were such that it enhanced objectivity and minimized biases and prejudices.

• Evidence Informed: The review was informed by data from national M & E frameworks, complemented by data from partners’ programs or projects, specific sector reviews and reviews of discrete elements of the response. It also took into account and incorporated scientific and technical developments in HIV/AIDS.

• Enhancing national planning: The review was a critical part of programming cycles, and the results will inform the development of the next NSP and future HIV programming.

• Sensitive to gender and human rights: The joint review process provided an opportunity to factor in these important cross-cutting considerations.

• Learning experience: A major consideration and benefit of the joint review process was that it enabled participants to learn from each other’s expertise and experience and contribute to building national capacity.

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2. MetHoDoLoGY of Joint Review

2.1 – oRGAnizAtion of tHe Joint ReviewThe joint review was organized according to the M&E plan of the NSP, supplemented by a number of CNLS documents outlining policies and guidance for HIV interventions and outlining key monitoring and evalua-tion indicators. As such, the joint review was organized into four major thematic areas according to the four strategic purposes, or axes, of the NSP: prevention, sur-veillance and research, care and treatment, and impact mitigation.

The last axis of the NSP incorporates general perfor-mance in planning, coordination, and monitoring and evaluation strategies. These strategies were considered to be cross-cutting and relevant to all other thematic areas. Aspects of planning, coordination, and monitoring and evaluation were assessed within each thematic area. In addition, the review extensively used the findings and recommendations from the Country Harmonization and Alignment Tool (CHAT) report to inform the assessment of the last axis. The CHAT exercise cov-ered seventeen public sector institutions, thirteen civil society and private organizations, and ten development partners and assessed the extent of mobilization, partici-pation and inclusiveness in the national response across all stakeholders.

Figure 2.1 displays the overall organization of the joint review. As is described in more detail below, the overall process was guided and led by an Oversight Commit-tee chaired by the Executive Secretary of the CNLS and comprised of high-level HIV stakeholders from all sectors and levels. The technical oversight of the review and the successful implementation of the joint review methodology were managed by a Joint Review Steering Committee (JRSC) chaired by the M&E Officer of the CNLS and comprised of technical staff members from the Planning & Monitoring and Evaluation Technical Working Group (PM&E TWG) on HIV/AIDS.

The JRSC established terms of reference for interna-tional and national consultants to assist with the review. The international consultants were provided by the UNAIDS and World Bank’s AIDS Strategy Action Planning (ASAP) Program and the UNAIDS Regional Technical Support Facility (TSF) for Southern Africa. International consultants assisted the JRSC in the de-

velopment of the joint review methodology, including protocol and data collection tools. International consul-tants assisted the JRSC in the drafting of this report.

Together, the JRSC and international consultants devel-oped four thematic, technical working groups (TWG) according to the four thematic areas and strategic axes of the NSP. TWG members were organized from mem-bers of the Planning & Monitoring and Evaluation Technical Working Group on HIV/AIDS and other HIV stakeholders. The JRSC also recruited a national consultant to chair each technical working group. The JRSC and international consultants were responsible for the data analysis and synthesis, and the production of the final report.

Oversight Committee: An Oversight Committee chaired by the Executive Secretary of CNLS was established to provide national-level advocacy for the overall process of the review and to give guidance to the Joint Review Steering Committee. Other members of the Oversight Committee included the Treatment and Research Center for HIV/AIDS, Tuberculosis, Malaria and other Infectious Diseases (TRAC Plus) and the Ministry of Health (MOH), the Rwanda Network of People living with HIV/AIDS (RRP+), United Nations institutions (One UN), the Global Fund for AIDS, TB and Malaria (GFATM), and the United States Government (USG).

figure 2.1 – organization of Joint Review

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In addition, the Oversight Committee was responsible for adopting the final report, and is responsible for ensuring the recommendations of the final report are integrated into the next NSP.

Joint Review Steering Committee (JRSC): In order to as-sure the successful implementation of the joint review, a Joint Review Steering Committee (JRSC) was estab-lished, chaired by the M&E Officer of CNLS and com-posed of members of the Planning &Monitoring and Evaluation Technical Working Group on HIV/AIDS. These members included TRAC Plus and MOH, UN-AIDS, UNDP, UNFPA and MEASURE Evaluation. The JRSC coordinated and managed the overall process of the review, including the following specific tasks:

• Development and management of thematic working groups.

• Adoption of joint review methodology;• Organization of all operations, including field

visits and national-level meetings and workshops.• Routine validation of intermediate results by the

Oversight Committee and other stakeholders.• Production of final consolidated report.• Collaboration with the Oversight Committee to

assure that recommendations will be implemented in the next NSP.

International Consultants: Technical and financial assis-tance for the joint review was provided by the UNAIDS and World Bank’s AIDS Strategy Action Planning (ASAP) Program and the UNAIDS Regional Training and Support Facility (TSF) for Southern Africa through the provision of three international consultants to assist in the review. The ASAP Program provided two prin-ciple consultants to assist the JRSC in the development of the review methodology. Once the final methodol-ogy was adopted, the ASAP consultants also trained the TWGs and related national consultants on the review methodology and provided peer review to intermediate reports produced by the TWGs.

In addition to the support from ASAP, the UNAIDS TSF also provided an international consultant to assist with the HIV Prevention component of the review. As HIV Prevention is a national priority (EDPRS cites re-duction in HIV incidence as one of three major results for the health sector), the JRSC decided that further targeted assistance for the prevention component of the joint review would assist in providing strong, evidence-based recommendations for the development of the next NSP. The international Prevention Expert worked

closely with the prevention TWG and national consul-tant to provide a substantive review of HIV prevention strategies in Rwanda.

Thematic and Technical Working Groups (TWG): For each of the four thematic areas, a thematic and techni-cal working group (TWG) was established to lead the review process. The TWGs were comprised of a wide array of HIV stakeholders at both the national and district level, including public and private institutions, UN organizations, and PEPFAR implementing part-ners. The members of each TWG were from the Plan-ning & Monitoring and Evaluation Technical Working Group on HIV/AIDS.

A national-level consultant was recruited to chair each TWG and ensure the successful implementation of the review methodology. The national consultant was responsible for developing a road map for each TWG, including document review, the adaptation of data col-lection tools, and the identification of all data sources relevant to the thematic area. The national consultants organized all consultative meetings with relevant stake-holders and the TWG and organized the field visits for each thematic area. Each TWG was responsible for providing intermittent reports to the JRSC for overall guidance and validation.

National Level Indicators: The M&E Plan puts forth indicators at each Output and Outcome level of the NSP and defines each indicator, including data sources and responsible agencies. Thus, the indicators for each Outcome and Output were assessed. However some of the Outputs and outcomes of the NSP did not lend themselves to objective assessment. This was largely due to the fact that many of the primary data sources or national-level databases identified in the M&E Plan as data sources were actually not developed, or were not designed to collect the data mentioned in the M&E Plan.

As a result, key questions to guide the review were developed by the thematic working groups. The ques-tions were selected based on an assessment of the NSP Outputs and outcome indicators and the available data sources. Proxy data was used wherever necessary to as-sess the progress made in achieving such Outputs and Outcomes. Overall, the key questions were the basis for analysis of the data/information collected. The Key Questions can be found in Annex A.

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2.2 – DAtA CoLLeCtionQuantitative Data Collection: The main sources of quantitative data were the relevant annual reports of the CNLS and TRAC Plus, the principal donor programs (USF, GF and World Bank’s Multi-country AIDS Project (MAP)), as well as the CNLS database and a small number of relevant studies and research indicating progress in relation to the key indicators (e.g. DHS, BSS, ANC surveillance and other studies). These sources provide information on the main strategies that have been employed in the national HIV response, as well as providing some indication of the results of implemented activities.

Qualitative Data: Qualitative data were obtained from studies or evaluations of programs, and were gathered during visits to selected districts, organized within the context of this review. The districts were selected from the four provinces of the country and Kigali city to en-sure that data/information collected was representative of the entire country. Within each province, 2 districts were selected based on urbanization criteria by applying the national categorization of rural and urban districts (i.e. one rural and one urban district was chosen per province). All three districts of Kigali city were selected as well. In total eleven districts were selected, constitut-ing over 30% of the districts in the country. Taking into account these broad principles for representativeness, the precise districts were then purposively selected, with an emphasis being placed on selecting districts where a variety of HIV programs were known to have been implemented during 2006-2008.

These visits to the districts included two principal activities:

• Meetings with the CDLS and key HIV/AIDS program implementers. The purpose of these meetings was to enable district-level actors to contribute to the NSP review by conducting their own appraisal of the strengths and weaknesses of the response to HIV/AIDS in their locality. Implementing organizations were drawn from civil society, private sector and public institutions. One meeting was conducted in each district.

• Focus group discussions with specific target groups. The purpose of focus group discussions was to assess how different target groups react to different interventions, to identify the most and least successful interventions for each group, and to identify gaps in service provision. More than 75 focus group discussions were conducted.

Field visits were conducted by members of the techni-cal working groups set up to coordinate the different components of the NSP review, under the guidance of national consultants and of CNLS staff members. Each of the four teams included members from each of the working groups, meaning that each team had a range of expertise in different aspects of the response to HIV/AIDS. The list of districts, of focus group discus-sions and of other relevant activities conducted in each district is provided in Annex 2.

2.3 – DAtA AnALYSiSFor each Outcome and Output of the NSP and indica-tor in the M&E plan (as well as indicators specified in other sources) data collection tables were prepared specifying the key questions, the likely sources of data for answering those questions, and the methods to be used to obtain data. Data from the different sources were compiled according to these tables in order to pro-vide a national level picture of the main achievements of the HIV response during the review period.

Based on this comprehensive data, overall conclusions were drawn in relation to the main gaps and lessons learned to be taken into account in the future. Primary analysis was carried out by the consultants and resource people leading the review. Over the course of the review the technical working groups, Joint Review Steering Committee and the Oversight Committee provided ad-ditional analytical input.

2.4 – LiMitAtionSIn general, neither the NSP nor the M&E plan includes national targets to be achieved for the various indica-tors. Some targets appear in other documents, but they do not cover the same timeframes and were developed some time after the beginning of the NSP. Annual reports related to the main funding sources (USG, GF or World Bank MAP) occasionally include their own program targets, but aggregating these is not always possible given that they do not all relate to the same in-dicators. The review is therefore limited in its ability to assess whether national HIV response efforts as a whole have over- or under-performed.

It should be noted that program monitoring data from individual implementing organizations were not includ-ed in the review for the most part. This is because of the high risk of double counting, as most implementer figures tend to be included in reports from the major sources already consulted. This means that the review of

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quantitative data is essentially macro-level as it is largely based on summary information.

Other important limitations noted include the following:

• For outcome and impact-level data, although the impact data that is available is of a high quality, there is very little data covering the period of the review. The two available national datasets were the 2005 DHS (general population) and the 2006 BSS (specific groups only).

• The main sources of data used for this review do not measure the same indicators in the same way. Hence while some sources emphasize numbers of activities, others emphasize numbers of people

reached by activities.• Program annual reports do not cover equivalent

years as some are based on calendar years and others on fiscal years, making compilation of data by year somewhat inaccurate.

• Overlaps between sources cannot always be identified, so double counting is still a risk.

• Some of the studies used as data sources in this review are questionable in terms of quality of data collected or analysis. Certain figures are presented in this review because it is the only relevant survey that is available and that includes indicators that can be compared to the baselines. However it is essential to keep in mind the numerous caveats around use of these data.

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3. Joint Review finDinGS: Hiv SeRviCe DeLiveRY

3.1 – Hiv pRevention: pRoGReSS

3.1.1 – Impact, Outcomes and Outputs under reviewRwanda’s HIV prevention strategy is outlined in Axis I of the NSP, and is further elaborated in the National HIV Prevention Plan (18). The Impact, four Outcomes and fourteen Outputs shown in Table 3.1.1 on page 75 were under review. Indicators for each result level are presented in section 3.1.2.

The National HIV Prevention Plan details the princi-ples and the types of activity to be implemented under most, but not all, of the 14 Outputs in the NSP. The plan also provides strategic and policy guidance, for instance on targeting, on quality control, and on newly introduced approaches to service delivery (such as provider-initiated testing). The plan pays particular at-tention to the organization and coordination of behav-ior change communication (BCC) activities. The plan also lists 15 priority target groups for HIV prevention efforts. Additional national-level documents outlining policies and practical guidance for some of the specific Outcomes and Outputs have also been produced:

• National Strategic Framework on Behavior Change Communication for HIV/AIDS/STI 2005-2009 (May 2004).

• National Operational Guide for Implementation of BCC Programs in Fight Against HIV/AIDS to Priority Target Groups (May 2006).

• National Condom Policy (November 2005).• National Standards and Directives for the

Voluntary Counseling and Testing and Prevention of Mother to Child Transmission of HIV/AIDS (January 2008).

3.1.2 – Progress to June 2008Assessing Impact

impact 1 indicator

Reinforce measures for preventing HIV/AIdS transmission

Change in prevalence of HIV/AIdS in people aged 15-24 years

The M&E Plan defines this indicator as the percentage of blood samples voluntarily given by pregnant women

aged 15-24 at ANC clinics which test positive for HIV, citing ANC sentinel surveillance as the primary data source. The plan also cites DHS as a retrospective data source. This indicator is considered to be the closest proxy for HIV incidence in the population aged 15-49. Neither the NSP, the National HIV Prevention Plan, nor the M&E Plan specifies a target to be achieved for this indicator. However, the report on integrating HIV into the Economic Development and Poverty Reduc-tion Strategy in Rwanda 2008-2012 (15) provides a target of 0.5% prevalence among those aged 15-24 by 2012, down from a baseline value of 1.0% in 2005. This baseline value is derived from DHS (4).

All currently available national HIV prevalence data are presented in Table 3.1.2 on page 76. Although the 2005 DHS provides a baseline for this indicator, at the time of writing there are no new comparable data on HIV prevalence rates, so it is not possible to ascertain changes in relation to this measure. On the other hand, HIV sentinel surveillance in antenatal clinics (ANC) provides both baseline values (obtained in 2005) and intermediate values (obtained in 2007).

With the exception of sites in Kigali, all of the ANC results for the different sub-groups shown in the table suggest a slightly higher prevalence in the 2007 study. However, neither the total nor any one of the categories shows an increase that is statistically significant at the 5% level, and the apparent reduction in HIV preva-lence in Kigali is not statistically significant at the 5% level.

Although as noted above, general HIV prevalence among all people aged 15-24 is the official proxy for HIV incidence, the ANC data provide an additional proxy group: HIV prevalence among women who are pregnant for the first time. HIV prevalence is higher in the 2007 sample (3.6%) than in the 2005 sample (2.9%), however the difference between the two is not statistically significant at the 5% level (p=0.059). Indications of relative levels of HIV prevalence between certain population groups can also be inferred from the results of VCT testing. A selection of available data is shown in Table 3.1.3 on page 77.

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These data confirm findings of the 2005 DHS and from ANC surveillance that HIV prevalence is considerably higher in Kigali than in other sites, that it is higher in urban locations compared to rural locations, that it is higher in women than men, and that it is higher within the higher age brackets. The data also suggest that pris-oners, female sex workers and truckers are at higher risk for HIV infection.

Assessing Outcomes and Outputsoutcome 1.1 indicators

Change high risk sexual behavior

Change in percentage of 15-24 year-olds reporting sex with non-martial, non-cohabiting partner in the last 12 months (Prevention plan, M&E plan)

Change in percentage of 15-24 year-olds reporting condom use last time they had sex with a non-marital, non co-habiting partner (defined as “high risk sex”) (Prevention plan, M&E plan)

The M&E plan cites the National Behavioral Surveil-lance System at TRAC Plus as the data source for these indicators. Though no formal surveillance system was established during the implementation period, some population-based surveys were carried out over the re-view period. At national level, baseline values for these indicators are provided by the 2005 DHS. As noted previously, the 2006 BSS, which was carried out with young people, sex workers and truck drivers, is also considered as a baseline for this review.

The available data for the two main behavioral indica-tors and for a third indicator (percentage reporting systematic condom use during the past 12 months) are presented in Table 3.1.4 on page 78. The table also shows the DHS (baseline) information for the same indicators in relation to the 15-49 age groups, for information. It should be noted that although the study population for the BSS in 2006 was people aged 15-24, only the data on 15-19 year olds are currently available. The table therefore includes both 15-19 and 15-24 age ranges, to ensure that comparisons are only made for similar population groups.

Table 3.1.5 on page 79 shows all of the national-level baseline data that are available on priority target groups for HIV prevention, for information. It should be not-ed that most of the data sourced from the 2005 DHS in this table is based on very small samples, so they

should not be taken as being representative. It should also be noted that the behavioral indicators collected on sex workers and truck drivers are not the same as the indicators collected for other population groups.

A recently published study by the NGO Mission of Hope provides further indications on HIV prevention behavior of sex workers in three districts: Rubavu, Ru-sizi and Nyaruguru (7). Because the study was limited to three districts, it employed a different sampling strategy to the BSS, and because the same variables were not included in the study questionnaire, it cannot be directly compared to the BSS baseline shown above. In each district, the level to which respondents felt there were obstacles to using condoms with clients were very varied, ranging from 15-71% of respondents. In all three districts sex workers said that clients were pre-pared to pay between 2-4 times more for sex without a condom.

output 1.1.1 indicators

Promote EABC (through IEC for behavior change)

Number of new messages that promote EABC (M&E Plan)

Percentage of people aged 15-24 who know how to prevent HIV transmission (Prevention Plan)

The M&E plan defines this indicator as the number of new or significantly different messages that promote ABC which are disseminated in the year, citing vari-ous intervention agencies as the primary data source. As such a document review of relevant documents was conducted in addition to focus group discussions and key informant interviews.

National policy, strategy and coordination for behavior change programs: Rwanda’s behavior change strategy is based on promoting EABC: Education, Abstinence, Be-ing faithful, and using Condoms. CNLS has produced two key documents to guide the implementation of IEC/behavior change programs: the National Strategic Framework on HIV/AIDS/STI Behavior Change Com-munication 2005-2009 (BCC Strategy) (10) published in May 2004, and the National Operational Guide for targeted BCC Programs (BCC Guide) (14) published in May 2006.

It is important to emphasize that because the BCC Strategy was published in 2004, it is not entirely consistent with the NSP and the National Prevention

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Plan, in particular in terms of the list of priority target groups. However, the core principles and processes for designing BCC programs that are outlined in the BCC Strategy remain relevant.

The BCC Guide takes the principles and processes outlined in the BCC Strategy a step further, providing analysis of the specific vulnerability factors character-izing the different priority target groups, defining key behaviors and messages to be promoted for each target group, and providing detailed guidance on how pro-grams for each target group should be implemented. The recommended approach with regard to “ABC” behaviors is to promote each differentially according to the different priority target groups. Accordingly, abstinence and fidelity are promoted for all groups, and condom promotion is generally reserved for groups considered to be high risk.

Implementation of IEC/BCC programs: A range of methods are used to deliver IEC and BCC, including but not limited to community events, mobile video shows, counseling, peer education, radio and television programs, posters and billboards, theatre, songs, docu-mentation centers, printed materials, and a telephone hotline. Many of these methods were used as part of organized thematic campaigns such as the “Global cam-paign” launched by the CNLS and UNICEF in 2005; the campaign on child protection organized by PCFA/Imbuto Foundation and the CNLS in 2006; the Wite-gereza campaign in 2007 aimed at encouraging parents to discuss sexuality, reproductive health and HIV/AIDS with their children (this is further discussed below un-der Output 1.1.3); and the “STOP Cross Generational and Transactional Sex” campaign organized by PSI in 2008. Rwanda also organizes an annual national AIDS day, which takes place during an Umuganda com-munity service day at the end of every year and during which awareness and dialogue on a key issue related to HIV are promoted.

Another major strategy has been the creation of youth anti-AIDS clubs. At the end of 2007 there were over 1,500 functional anti-AIDS clubs, whose main activi-ties are to transmit messages on HIV prevention and responsible sexual behavior to young people and the broader community. There is an apparent decrease in functional Anti-AIDS clubs from 2006 (4,878) to 2007 (1,518). Members of the prevention technical working group suggested that these data can be interpreted in different ways: on the one hand they may imply that

after being set up, many clubs do not continue to orga-nize regular activities; on the other hand it may be that the change in the law requiring associations to become co-operatives has led to many Anti-AIDS clubs being no longer officially recognized. Other informants suggested that the district-level reporting on which the 2007 figures are based may have failed to capture the correct numbers. Overall, existing data about the level of effort for each type of IEC/BCC activity are incomplete.

People trained to deliver IEC/BCC programs and other prevention services: Data on the numbers of people trained to deliver IEC/BCC programs are reported by several sources. Some sources disaggregate data accord-ing to the content of training, whereas others disaggre-gate it according to the profile of those being trained. The range of beneficiaries shows that delivery of IEC/BCC programs is not limited to health facilities, and that they aim to reach people in real life contexts. The summary provided in Table 3.1.6 on page 79 focuses on content, and estimates the proportion of those trained to deliver abstinence and be faithful only (AB only) messages as opposed to those trained to deliver compre-hensive ABC in 2006 and 2007.

As the table shows, in the two years for which complete data is available the proportion trained to deliver AB-only IEC/BCC is between 80-90%. According to the members of the prevention technical working group, this high percentage may indicate that a large propor-tion of IEC/BCC initiatives target young people in schools, as condom promotion tends not to be accepted in schools. The proportion also reflects the priorities of donor agencies, for instance the USG requirement for its programs to prioritize AB-only prevention.

People reached by different prevention methods: As already noted, a range of methods are used to reach people with the aim of changing risky sexual behavior. Table 3.1.7 on page 79 outlines approximate numbers of people reached according to broad categories: the first, outreach, includes peer education, community discussions, Anti-Aids clubs, and events such as mobile video shows. The table does not include people reached by mass-media methods.

Overall the table shows that IEC/BCC programs reach a considerable proportion of the population, and taking into account that data for 2008 is incomplete, it shows that numbers of people reached have been steadily increasing. Unfortunately the available data do not

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make it possible to assess what proportion of people are reached by different messages, in particular the balance between messages focusing solely on AB only and mes-sages that include promotion of condom use. Similarly, the data do not provide a detailed picture of how these different interventions are targeted, and the extent to which priority target groups are reached. The narrative sections of the reports cited suggest that the overwhelm-ing focus is on young people, in particular those in school, with the other main target group being the gen-eral population (reached through community events).

In 2007 the CNLS, with the support of UNDP, con-ducted an evaluation of the extent to which the BCC Guide is followed by IEC/BCC programs (13). The main conclusion was that although many of the organi-zations contacted were not aware of its existence or were not actively referring to it in their work, most of them were essentially keeping to the spirit of the BCC Guide. In some cases there was a concern that implementers were not covering all of the proposed messages for each target population. However the biggest challenges that were identified related to funding, planning and moni-toring BCC activities and to ensuring that sufficient materials were available to support BCC programs.Quantitative data on results of IEC/BCC programs: The main source for tracking numbers of new mes-sages is the national BCC committee. According to the annual CNLS activity reports and to the committee itself, 39 new messages or products were approved in 2006, 16 in 2007 and 47 in the first semester of 2008 (20; 22). However, the number and type of new mes-sages, and the extent to which programs follow national policy, are not in themselves adequate indicators of the results of IEC/BCC programs.

The 2005 DHS and 2006 BSS provide national baseline values on HIV-related knowledge that can be disaggregated according to some of the priority target groups. Since no more recent DHS or BSS studies have been conducted at national level there are no compa-rable data which can be used to gauge changes since the baseline in relation to these indicators. All available national data on knowledge are presented in Table 3.1.8 on page 80. The table includes both 15-19 and 15-24 age ranges, to ensure that comparisons are only made for similar population groups.

A recently published study by the NGO Mission of Hope provides an indication of the levels of knowledge on HIV prevention among sex workers (7). As noted

above, the data from this study are not easily com-parable with the BSS data. Nonetheless, like the BSS study the Mission of Hope study suggests that levels of knowledge on HIV among sex workers are generally high, with only a small number of respondents provid-ing incorrect answers. Over 95% of all respondents cit-ed condom use as a means of preventing HIV transmis-sion, with no significant variations between respondents in the three districts. This estimate is a little higher than the value obtained by the BSS (83%).

Qualitative data on results of IEC/BCC programs: The key informant meetings and focus group discussions conducted as part of this review indicated that basic knowledge on HIV/AIDS within the different target groups is generally high. The majority of focus group participants were able to describe how HIV is transmit-ted as well as knowing the main ways of preventing HIV transmission. Focus group participants also cited a range of sources of information on HIV/AIDS, indicat-ing that for the most part people are being reached by BCC messages in a number of different ways.

Most of the sources of information cited were mass communication channels, including radio messages, billboards, and posters; it was less common for par-ticipants to say that they had received information via outreach-type approaches such as community theatre, participatory discussions and peer education, or direct counseling. Although most of the participants had received information from mass communication and outreach sources, a number had also obtained informa-tion from dedicated centers and in health care settings: feedback on the availability of prevention information from Anti-AIDS clubs, and from clinical settings in-cluding youth-friendly centers, was generally good.

On the other hand, in a number of cases focus group participants revealed that there was little continuity to programs throughout the year. It also emerged that very few people had received printed materials on HIV/AIDS, such as leaflets or books. Visits to certain key sites for the delivery of HIV prevention information (such as schools, Anti-AIDS clubs, and “hotspots”) re-vealed that many had run out of materials to distribute to program beneficiaries; none of the “hotspots” visited had any visible information on HIV/AIDS.

In a small number of cases, it emerged that printed ma-terials do not take into account the different languages spoken by Rwandans, or by people travelling through

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Rwanda such as long-distance drivers. It also appears that some groups are being reached less effectively by IEC/BCC programs. People who work alone for long periods of time such as long distance drivers and fishermen/women said that they found it hard to get information. There was also evidence that the specific requirements of people with disabilities are not always addressed, making IEC/BCC programs largely inacces-sible to them.

Although responses obtained during the fieldwork indicated that IEC/BCC programs have generally been effective in ensuring that levels of basic knowledge on HIV/AIDS are high, there are indications that the in-formation that is transmitted is somewhat limited. The ability to describe how HIV is transmitted and how to prevent it was seldom matched by more in-depth knowledge on sexuality, sexual and reproductive health, and even on the human body and STIs.

In a number of focus groups, the responses given by participants about how they acted on the informa-tion they had suggested that they did not necessarily have the skills or the ability to understand and act on messages such as abstain, be faithful and use condoms. Hence, participants often said that they believed in or were committed to adopting one of these preventive be-haviors, while their other responses suggested that this may not correspond to their actual behavior but just respond to what they consider as socially desirable. An example of this was a group of boys attending school, who universally stated that they abstained from sex, but later said that they needed better access to condoms.


Increase access to and use of condoms

Number of condoms sold or distributed to end users, broken down by type of user (M&E Plan)

Number of social distribution points for condoms (M&E Plan and Prevention Plan)

The M&E plan defines this indicator as the number of condoms distributed annually to end-users by govern-ment facilities and projects, citing social marketing agency reports collected by CAMERWA and CNLS as the primary data source. Rwanda’s national con-dom policy was published at the end of 2005 (17). The policy positions condoms as a key component of HIV prevention, to be widely promoted in the context

of sexual health and sexuality education. One of the fundamental approaches of the policy is to improve the way condoms are perceived so that they are not stig-matized or loaded with negative connotations, because these connotations constitute obstacles to condom use. The policy therefore calls for multi-sectoral commit-ment to condoms, including support from religious, community and political leaders.

Further evidence of the national commitment to pro-moting condoms and making them available is found in the EDPRS-HIV integration document, which includes measures aimed at making condoms more ac-ceptable as well as including as one of its key indicators an increase in condom use during high risk sex among people aged 15-24 (15). The Prevention Plan also outlines the need for increased condom promotion, and states that condom distribution should increase over the NSP period (18).

Condom promotion and distribution approaches: Dur-ing the period under review, condoms were distributed for free through public sector institutions (generally within the context of workplace HIV programs) and sold through the private sector. The large majority of sold condoms were heavily subsidized and sold under a social marketing brand, Prudence Plus. Female con-doms were distributed through health facilities and tar-geted programs. A recent rapid assessment on condom programming in Rwanda states that there is very little mass media promotion of condoms and that condom distribution within the context of HIV programs is for the most part targeted towards groups considered to be high risk (5).

Quantitative data on condom distribution: Condom distribution is a feature of all the main HIV prevention programs in Rwanda — i.e., the World Bank MAP, Global Fund grants, and USG programs. Table 3.1.9 on page 81 shows the data that are currently available on male condom distribution. The data in the table all relate to male condoms.

The data in the table need to be interpreted with cau-tion. Although the table seems to indicate that numbers of condoms distributed have decreased year from year, this is an incorrect conclusion, as it is clear that data are incomplete, and the figures for 2006 may be inflated (see note to table). However, the table does provide some interesting detail on how condoms are distrib-uted. It shows that condoms are distributed in Rwanda

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both via free distribution and through the sale of sub-sidised condoms, and although the sources of data are not specific enough to provide a precise estimation, it suggests that at least half of all condoms distributed are sold via social marketing. Also of interest is the implica-tion that the large majority of free condoms are distrib-uted via the public sector (essentially as a workplace strategy), with very few condoms distributed for free through community or civil society sector partners.

As the table indicates, the data on condoms are very inconsistent between different sources. Overall, current data are very inconsistent between different sources. A calculation of condom consumption is presented in the report of the recent rapid assessment on condom programming (5), see Table 3.1.10 on page 82. This calculation includes condoms distributed under family planning programs, and has been compiled based es-sentially on data from HIV programs.

Data show a modest increase in condom consump-tion overall between 2006 to 2008 (a less than 2% increase), although estimated consumption in 2007 was lower than it was in 2006. Data on the consumption of female condoms are also inconsistent. None of the principal sources for this review provide information on female condoms. The Ministry of Health’s 2006 annual report states that 7,770 were distributed during that year (25), and the 2007 MOH report does not mention female condoms. On the other hand, the rapid situ-ational assessment for condom programming provides a figure of 2,000 female condoms for 2006, 4,200 for 2007 and 5,500 in 2008. In each case, however, it is clear that female condoms do not yet represent a signifi-cant proportion of overall condom use.

Data on condom availability: Condom availability – and the ability of users to access them when needed – is also a crucial consideration. A study carried out on behalf of PSI and the CNLS in 2005 provides baseline data on condom availability (28). The study showed that condoms were available in 93% of urban cellules and in 56% of rural cellules. Nearly three quarters of respon-dents to the survey stated that it was important to be able to access condoms at any time of the day, and there was a significant preference (75%) for obtaining con-doms from small shops and kiosks; the same proportion supported public availability of condoms and an even greater proportion (85%) supported the provision of public information on condoms. And yet, over half of respondents said that they were discouraged from

condom use by the image and reputation that buying condoms might give them, and a significant minority (22%) opposed making condoms publicly available on the grounds that it would encourage casual sex. A large proportion of respondents – over 60% – said that stock outs were an obstacle to consistent condom use. Lack of knowledge of how to use condoms was cited by 54% of respondents as another major barrier to condom use.

The condom availability study does not provide infor-mation on the number of locations where condoms are available, although it does state that they are more likely to be available in shops, kiosks, pharmacies, and health facilities, and less likely to be available in “hotspot” locations such as bars. This is further confirmed by the PLACE study carried out in 2006 (12). National data on the number of condom outlets are incomplete. The condom programming rapid assessment provides some figures on the availability of condoms in public health facilities: in September 2008 only 55 percent of these facilities had condoms. HIV services contacted during the assessment reported that stock-outs and shortages mean that condoms are not always available.

According to the rapid assessment, condom availability is often determined by the authorities in any given situ-ation. Hence, there is no explicit guidance for or against condom provision in school Anti-AIDS clubs, and con-dom availability therefore depends on the school prin-cipal in each case. However, this lack of explicit policy also means that even in cases where the relevant author-ity — for instance a school principal — does want to make condoms available, the supply mechanisms to get condoms to the location are not necessarily in place.

Qualitative data on condom distribution and availability: Data collected during site visits and focus group discus-sions at district level, as part of this review, confirm many of the findings emerging from the 2005 baseline. Knowledge of condoms as a means of HIV prevention was high in all groups, respondents generally had posi-tive attitudes towards condoms, and condom avail-ability was said to be good in urban locations. Good examples of how condoms are accepted included one group of truck drivers saying that they always travelled with condoms, and staff from one bar saying that they included condoms in the price of a beer. People living with HIV also said that they were able to get regular supplies of condoms from health centers. On the other hand, many respondents said that knowledge of how to use condoms correctly was limited. At a societal level,

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negative perceptions continue to affect peoples’ will-ingness to use condoms: they are still associated with shame, making people fear that they will be perceived negatively. False information about condoms — for instance that they are dangerous or that their use can interfere with breastfeeding — exist, although they are not common. During one focus group discussion it was stated that parents are responsible for spreading false rumors about condoms in order to discourage their children from using them. On several occasions, imple-menters at district level said that religious organizations actively oppose condoms.

Resistance to condom use appears also to be related to personal preferences. Many people do not like using condoms either because they are not used to them or because they feel that they interfere with sexual plea-sure; men were seen as being particularly reluctant to adopt condom use. In addition, a number of partici-pants said that they were not opposed to condoms as such, but that they felt that the condoms available were of poor quality, and occasionally past their usage date.

Furthermore, for each good example of condom avail-ability, there were several examples of problems. Con-doms are not available in most bars, discos and hotels; many long distance drivers said that they often found it hard to get condoms; and condom availability in rural areas is severely limited. Not surprisingly, condoms are far less easy to come by at night when many people need them the most. An interesting phenomenon which was mentioned several times is that condom prices often go up in the evenings, sometimes to a level that users cannot afford. Stock-outs of condoms seem to occur frequently, and many programs or service pro-viders do not supply condoms — in particular health facilities that are run by religious organizations, but also most of the anti-AIDS clubs. During focus group discussions with prisoners — including prisoners living with HIV — it was confirmed that condoms are not available in Rwandan prisons.


Educate youth on sexual responsibility

Number of schools that receive sex education and/or life-skills curriculum and are trained in its use (M&E Plan)

Increase in the percentage of never-married 15-24 year olds who have never had sex (Prevention Plan)

This Output has some aspects in common with Output 1.1.1 as many of the delivery strategies, such as mass communication campaigns and Anti-Aids clubs, relate to both Outputs. Although the key indicator for this Output in the M&E Plan relates to schools, the strategy also includes out of school youth and education provid-ed by parents to their children. At present it is estimat-ed that 140 schools are implementing programs aimed at providing life skills education to pupils (3). Table 3.1.11 on page 82 summarizes the numbers of teachers trained to deliver life-skills education in schools and the number of school pupils receiving the training.

The half-year figure for 2008 shows that school-based life skills education is reaching a very significant pro-portion of Rwandan schoolchildren; however to date there is no information on the extent to which this education follows established norms.

Quantitative data on programs to educate young people on sexual responsibility: As mentioned above, one report indicates that 140 schools are currently implementing life skills education: this represents 42% of all schools (43). The DHS 2005 provides a baseline value for attitudes of parents towards sexuality education for children — specifically in relation to teaching children about condom use (Table 3.1.12 on page 82).

The baseline value for this indicator shows that a very high proportion of adults (over 80%) states that they support teaching children aged 12-14 about condom use. Data are available on the proportion of young people who have never had sexual intercourse, and are presented in Table 3.1.13 on page 82. Since BSS data for the full 15-24 age range is not yet available, two sets of data are presented: one for 15-19 year olds and one for 15-24 year olds. The UNICEF KAP study data from 2007 are presented with reservations due to meth-odological problems.

The scale of the differences in values obtained by the different sources for people aged 15-19 does not appear to be significant. The findings of the recent UNICEF study for people aged 15-24 do suggest significantly higher levels of sexual activity than was the case for the DHS; however, the UNICEF data should not be seen as evidence for changes since the baseline.

Qualitative data on programs to educate young people on sexual responsibility: The focus group discussions con-ducted as part of this review confirmed that sexuality

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education is a feature in many schools. Discussions with young people in school, as well as site visits to a number of secondary schools, showed that HIV education is being integrated into mainstream teaching, and some schools have conducted testing campaigns with support from mobile testing units. However, it emerged that schools do not always have adequate teaching materi-als, and that in many cases teaching is limited to HIV rather than being linked to broader themes related to sexuality and sexual and reproductive health.

The focus group discussions revealed that there are major barriers to dialogue on sexual health and sexu-ality between parents and children. Responses from parents participating in discussions were somewhat varied, with some stating categorically that they did not agree with providing sexual health information to their children, others stating that they were too embar-rassed to discuss these issues with their children and that they felt schools and Anti-AIDS clubs were doing the job sufficiently well, and others still saying that discussing sexual health with their children was their responsibility. Importantly, many of the parents who said they agreed that it was important to discuss with their children admitted that they were not sure how to go about it: they felt that they did not have the knowl-edge or the skills. Although the idea of discussing with their children was accepted, many could not actually go through with it.

Those parents who were the most open about discussing sexual health and HIV prevention with their children appeared to be those who had had in-depth training on HIV prevention: parents who had been trained as peer educators and parents living with HIV stood out as being the most progressive, some of them even stating that they would provide their children with condoms in order to make sure they were protected.

Young people participating in the focus group discus-sions confirmed that for many of them, discussing sexual health and HIV with their parents was impos-sible, and that where it did happen the advice provided by parents was not particularly helpful. Others go as far as saying that condoms are dangerous, in order to discourage their children from having sex. The majority of young people participating in the focus group discus-sions said that they did not dare to talk about these issues with their parents, either through embarrassment or because it would involve admitting to their parents that they were already sexually active.

output 1.1.4 indicator

Increase the number of people in the population that know their HIV/serological status

Number of persons tested who come back to VCT centers for results (M&E Plan)

The M&E plan defines this indicator as the number of persons tested in VCT centers which report to TRAC Plus and return to get their results, citing VCT site monthly summary reports as the primary data source. The National Prevention Plan, revised in 2006, outlines a dual track strategy for HIV testing in the general population: making VCT services available to the entire population and introducing provider initiated testing for HIV in health care facilities. The Prevention Plan also emphasizes the requirement for HIV testing of blood and organ donors.

Measures aligned in the prevention plan to improve testing capacity include not only increasing the number of sites where tests are available, but also improving testing infrastructure to make testing facilities more efficient – for instance by delivering test results more quickly. The Prevention Plan gives particular impor-tance to reach more couples and men with HIV testing. National guidelines on VCT (as well as prevention of mother to child transmission) were published in early 2008. According to the guidelines, the objective of a VCT service is to help the individual to make better decisions concerning his/her sexual behavior and to reduce the risk of HIV transmission.

The document provides detailed guidance and crite-ria for delivering testing both within existing health facilities and in other settings, including mobile test-ing facilities — the guidance covers requirements for infrastructure and equipment, as well as norms for the provision of training to those involved in delivering testing. It emphasizes the requirement for informed consent from people undergoing testing, whether it is carried out as VCT or on the initiative of health care providers (provider initiated testing — PIT).

Scale up of HIV testing has been a major emphasis of the period covered by this review. At the start of the period covered, end 2005, 229 sites were offering test-ing. The Prevention Plan states that the aim by the end of 2009 is to have 400 testing sites with the preferred approach is to integrate testing with existing health facilities rather than setting up stand alone testing

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sites. By the end of 2007, 313 sites were offering HIV testing – these include hospitals and public and private community health centers. This is a little higher than the objective of 305 sites that was set for end 2007. By June 2008, 345 sites were offering testing. In addition, the advanced strategy of providing mobile testing has been effectively introduced, meaning that in effect the number of testing sites is even higher. Mobile testing is particularly targeted at most-at-risk populations.

The expansion in numbers of testing sites is mirrored by increases in the numbers of people trained to deliver testing services: for instance, in the first semester of 2008 alone, over 2000 service providers have been trained in HIV testing by Global Fund projects.

Quantitative data on HIV testing: Data on numbers of people receiving HIV testing are centralized by TRAC Plus and are less subject to inconsistencies and double counting between sources. TRAC Plus also reports some targets for the numbers of people to be tested. Table 3.1.14 on page 83 shows the annual targets where available, data on total numbers tested, as well as results for the key indicator for this Output, the proportion of people testing who receive their test results. It also shows numbers tested by mobile testing sites. All data were obtained from TRAC Plus annual reports unless otherwise noted.

As the table shows, there is a steady progression in the numbers of people being tested for HIV, and the numbers tested per year represent a significant pro-portion of the Rwandan population. If testing rates continue at their current pace it looks likely that a test will have been administered for more than one in every ten Rwandans over the course of 2008. This does not mean that 10% of Rwandans take an HIV test each year because some people may have tested more than once. However this level of testing suggests that the percentage of “ever-tested” Rwandans is likely to be higher than the levels measured during the DHS survey in 2005, when 23.4% of respondents had ever had an HIV test.

Where data are available (2007 and 2008), the percent-age of people receiving counseling who then agree to take an HIV test is very high (>99%). The targets for numbers to be tested set by TRAC Plus for 2006 and 2007 were met and surpassed, and mid year figures for 2008 indicate that the number of people being tested is still increasing. Data on the percentage of people tested

who receive post-test counseling were not found in any of the source documents. However, the percentage of people receiving their test results – 97% in 2007 – is also encouraging, as the DHS survey had indicated that in 2005 fewer than 90% of people receiving testing had also received their results. However, the half-yearly results for 2008 show that the percentage receiving their results has dropped to 94%. The percentage of mobile testing clients receiving their results is not reported, although there are anecdotal reports that the percentage is lower than for fixed testing sites.

As noted above, as well as increasing the numbers of people tested, the advanced mobile VCT strategy is designed to reach most-at-risk populations. As the data in the table for 2007 show, in contrast to facility-based testing, more men than women are tested via mobile VCT. This is likely to be related to the fact that mobile VCT efforts have targeted predominantly male groups such as prisoners and soldiers (over 7,000 individuals in each category were tested through mobile VCT in 2006). The availability of testing facilities in prisons has improved significantly in 2008, with at least 8 prisons introducing testing since the beginning of the year (30). In these 8 sites, nearly 14% of prisoners have had an HIV test.

Qualitative data on HIV testing: The meetings with district-level implementers, and the focus group discus-sions with different population groups, confirmed the impression that there is increasing acceptance of HIV testing in communities. Availability of testing in urban centers was felt to be very good. While access was said to be good for some groups that are often considered marginalized — like prisoners, sex workers, and refu-gees — there was concern that some groups, like young people who are not in school, and men in general, are less likely to go for HIV testing.

Some important issues were raised both in relation to the delivery of testing and in relation to peoples’ at-titudes to testing. Issues in the delivery of HIV testing included that, for participants in rural areas, testing services were still not easily accessible and testing is perceived as taking up too much time. A number of participants expressed concerns that confidentiality was not sufficiently respected in testing centers, and that the advice given after a test is minimal. Many participants also stated that there is still quite a high level of shame associated with HIV testing, and fear of stigmatization. These difficulties are often observed where the testing

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sites are public: the facility on the university campus at Huye was given as an example. Elsewhere it was sug-gested that the relevance of testing is still not universally understood.


Increase the proportion of the population that knows causes, symptoms and consequences of STI, opportunistic infections, and TB

Number of new messages targeting an increase in knowledge of symptoms of STI, OIs and TB (M&E Plan)

Percentage of the population knowing the causes, symptoms and consequences of STIs, OIs and TB (Prevention Plan)

Percentage of people with STI symptoms in the past 12 months who accessed treatment (Prevention Plan)

The M&E plan defines this indicator as the number of new or significantly different messages that promote increase in knowledge of symptoms of STI, OI and TB which are disseminated in the year, citing intervention agency reports as the primary data source. The strategies aimed at achieving this Output are the same as those adopted for Outputs 1.1.1 and 1.1.4: different IEC techniques, including mass media, peer-education, An-ti-AIDS clubs, and school based education. Essentially, this Output is aimed at ensuring that broader issues around STIs, opportunistic infections and tuberculosis are integrated into communication for HIV preven-tion. The Prevention Plan states that awareness raising campaigns on the importance of treating STIs should be carried out at community level.

The only sources providing specific information in relation to this Output are the reports on Global Fund programs. The integrated HIV/TB program supported by the Global Fund has placed a particular emphasis on increasing awareness on tuberculosis, using various communications methods (radio and printed materials) as well as training providers to inform people on tuber-culosis symptoms: over 1,000 health care workers were trained in 2006 (41), and over 5,000 community health workers were trained in 2007 (42).

Quantitative data on STI/OI/TB knowledge: Although programs conducting IEC/BCC are increasingly ad-dressing STIs, no hard data on the number of mes-

sages specifically related to STIs, or to Opportunistic Infections, have been identified. The 2007 TRAC Plus annual report states that various information materials, including 15,000 booklets on OIs and 680,000 on STIs were printed over the course of the year (34), however members of the prevention technical working group stated that these have not yet been widely disseminated, and there is little evidence that specific awareness rais-ing campaigns on STIs have been implemented.

Table 3.1.15 on page 83 outlines the values that are available for the two indicators included in the Preven-tion Plan, as well as for two additional indicators which are relevant and which have been tracked in more than one source (having heard of STIs and reporting at least one STI symptom in the past year).

The relevant indicators have not been consistently tracked over time, and changes over time cannot be observed. Moreover, some of the differences reported by different sources for the same indicator are surprising: for instance, according to the 2005 DHS, fewer than 1% of young people aged 15-19 reported having had an STI symptom in the past year, whereas the 2006 BSS (conducted less than a year after the DHS) shows much higher rates: over 3% for men and over 7% for women. It is unlikely that random error explains this difference as the samples were relatively large (between 1,000 and 2,000 in each stratum). However, it seems unlikely that STI prevalence should have increased so dramatically in such a short time, and it is therefore possible that this indicator was measured differently by these two studies.

Qualitative data on STI/OI/TB knowledge: The findings from site visits and focus group discussions confirm what is shown in Table 3.1.15 at a basic level most people have heard of STIs. Focus group participants on the whole were able to name some STIs. However, participants who had good knowledge of STIs and who reported good access to STI treatment services were in a minority.

The data suggest that people are more likely to report good access to STI services where they are benefit-ing from a comprehensive prevention program, that involves the delivery of a “package” of information, education, products and services, rather than providing these things in isolation. Hence, some of the sex worker focus groups which had benefited from targeted pro-gramming were among those reporting the best access to services.

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Knowledge of STI symptoms was very limited, and participants reported that IEC/BCC programs provided very little information on STIs. It was also reported that STI treatment is expensive, and that health care workers can be judgmental when patients present with STIs. Shame and stigma surrounding STIs were said to be a contributing factor in people not seeking prompt treatment. Many participants expressed a preference for seeking treatment from traditional healers.

outcome 1.2 indicators

Change behavior of health personnel to reduce transmission of HIV/AIdS, STI, OI and TB

Percentage of facilities where the team is practicing safe injections (M&E Plan)

Percentage of transfusion blood units tested for HIV in the past year (Prevention Plan)

The M&E plan defines this indicator as the percent-age of health facilities in which all team members are using safe injection techniques as per national norms and procedures. The plan further cites summary reports of health facility site supervision as the primary data source. These reports were not systematically collected over the review period and weren’t readily available for document review; as such the relevant documents collected were analyzed. JSI is implementing a program (MMIS) under PEPFAR funds to decrease unsafe injec-tions in several districts in the country. An assessment of hospitals and lower-level facilities in Rwanda to look for changes in injection safety and health care waste management in the districts where the project is imple-mented is ongoing. For indicator 2 refer to Output 1.2.3 below.


Adopt universal precautions in health-care related establishments

Number of health care personnel who are trained in Universal Precautions (M&E Plan)

Percentage of safe injections (Prevention Plan)

The M&E plan defines this indicator as the number of personnel trained according to national training criteria on one or more aspects of universal precautions, further citing the CNLS intervention database as the primary

data source. As this database wasn’t developed over the review period, a document review was conducted to assess progress. According to the Prevention Plan, at the start of this review period no program had yet been put in place to ensure protection of health care personnel from HIV. The strategies outlined in the Plan to put in place such program are: training in WHO universal pre-cautions; provision of necessary equipment to all health care facilities, and support for integration of traditional birth attendants into the official health care system.

The main strategies for achieving this Output have been the development of guidelines, and training of health care personnel. Guidelines were circulated to all health facilities. Data on training of health care person-nel are relatively scarce; USG reports show that 6,759 individuals were trained in “medical injection safety” in 2006, and that a further 2,210 individuals received this training in 2007. No data on the percentage of injec-tions delivered safely have been identified. The data on training indicate significant efforts to improve safety in health care settings, although they do not provide a clear indication of the extent to which Universal Pre-cautions are applied.


Adopt provider-initiated diagnosis of STIs, OIs and TB

Number of persons who receive treatment for STIs (M&E Plan)

The Prevention Plan briefly outlines policy for STI treatment: syndromic management, along with labora-tory testing for suspected syphilis. The key strategies for expanding STI treatment include training of health care workers and provision of supplies for diagnosis and treatment. Alongside expanded treatment provision, the Plan includes expanded awareness-raising on STIs (see Output 1.1.5). Provider initiated-testing for STIs, OI and TB is not specified in the Prevention Plan. In prac-tice, health care practitioners have begun to implement systematic referral of TB patients for HIV testing.

The sources used for this review provide very few details on programmatic efforts to improve treatment of STIs. Policies and guidelines on provider initiated diagnosis of STI, OI and TB, were developed and disseminated to all facilities in 2006. Numbers of people treated for STIs are only reported in one source: the Global Fund semi-annual report for 2008. According to the report 31,688 people received STI treatment. The national

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HIV testing policy states that STI patients should be systematically referred for HIV testing; however data on referral rates do not appear to have been captured. During the period, TRAC Plus introduced a policy to ensure that all TB patients are tested for HIV and all HIV patients are screened for TB. Data on rates of test-ing of tuberculosis patients for HIV are shown in Table 3.1.16 on page 83.

In 2007 Rwanda earned a WHO award in recognition of the high HIV testing rate for tuberculosis patients; as the table shows the half-yearly figures for 2008 show a further increase in this rate.


Adopt blood safety measures

Percentage of transfused blood units which were screened in last 12 months (M&E plan)

The M&E plan defines this indicator as the percentage of transfused blood units which were screened in the last 12 months according to national guidelines, citing the National Blood Transfusion Center (CNTS) annual reports as the data source. The Prevention Plan outlines steps to integrate HIV prevention into the national blood transfusion service through training and intro-duction of HIV counseling to potential blood donors.

Data from the National Centre for Blood Transfusion shows that in 2006 and 2007 100% of donated blood units were screened for HIV in a quality assured man-ner, following a documented standard operating proce-dure and participation in an external quality assurance scheme. The number of blood units collected has risen from around 29,000 in 2004 to 38,539 in 2006, of which 1.7% tested positive for HIV.

outcome 1.3 indicator

Reduce the transmission of HIV through medical prophylaxis

Proportion of all HIV+ pregnant women given medical prophylaxis (M&E Plan)

The M&E plan defines this indicator as the percent-age of HIV+ pregnant women attending PMTCT sites that are given complete antiretroviral prophylaxis according to current protocol in the last 12 months. The plan cites PMTCT site reports from TRAC Plus as

the primary data source. The data for this indicator are presented in Table 3.1.17 on page 84. A comparison of treatment rates in 2006 and 2007 shows a big increase in the percentage of HIV positive women who receive ARV prophylaxis: from 69% to 96%. The percentage shown in the table for 2008 is much lower than that for 2007 (67%), but this should not be assumed to mean that the treatment rate has fallen, because the data available from TRAC Plus for 2008 were incomplete and provisional.

outputs 1.3.1 & 1.3.2 indicators

Motivate more pregnant women and their partners to use PMTCT services

Number of pregnant women who use PMTCT services (M&E Plan)

Increase access to high quality PMTCT services

Number of PMTCT sites using national protocol (M&E Plan)

The Prevention Plan outlines plans for achieving national coverage of PMTCT. More detailed techni-cal guidance on PMTCT was provided in 2008, in the National Guidelines on VCT and PMTCT (27), em-phasizing the need to ensure PMTCT counseling covers not just HIV but also safe motherhood, family plan-ning and child monitoring, and providing a detailed protocol for delivery and for administration of ARV to HIV positive pregnant women.

Quantitative data on progress in providing PMTCT: Expansion of PMTCT services has been carried out through integration with maternal and child health services. Table 3.1.17 on page 84 outlines some of the key figures relating to the PMTCT program.Although data for 2008 are incomplete, the comparison of data to date show rapid increases in the numbers of PMTCT services: 77% of health facilities now provide PMTCT, up from a baseline of 49% at the end of 2005. The data suggest that there are consistent improvements in the percentage of partners of women attending PMTCT who agree to be tested.

Qualitative data on progress in providing PMTCT: Data collected during focus group discussions with PMTCT program beneficiaries suggest that strengths of the pro-gram are as follows:

• Community health workers have been active in promoting PMTCT at community level.

• Stigma is not a major concern for women in the program.

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• Many program participants receive other forms of support (e.g. CBHI).

• ARV and bactrim prophylaxis access for infants is said to be good.

The field work also revealed a number of weaknesses:• Unmarried women are marginalized from ANC/

PMTCT as they are unable to prove that they are unmarried.

• Many men are hesitant to attend.• Nutritional support is not adequately provided to

all HIV+ pregnant women.• Nutritional supplements for children being

weaned are lacking — many women continue to breastfeed after 6 months as a result.

• Adherence to bactrim prophylaxis by children is not ideal as follow up is not optimal.


Assure Post Exposure Prophylaxis (PEP) for health care personnel

Number of public health facilities which have PEP kits available (M&E plan)

Assure PEP for rape victims Percentage of providers trained in identification, care and treatment of rape victims (M&E plan)

The M&E plan defines these indicators as the number of public health facilities that have a regular stock out of PEP kits with national standards, citing supervision reports as the primary data source; and the percentage of providers completing training in the identification, care and treatment of rape victims, citing the CNLS intervention database as the primary data source, respectively.

As mentioned above the supervision reports were not available for document review and the CNLS interven-tion database was not developed to capture this type of information. Instead a review of relevant documents was conducted. Guidelines for PEP were developed and disseminated to all health facilities; similarly, guide-lines on medical care for victims of rape were devel-oped. Training on medical care for victims of rape was planned for 2007, but no data have been identified to confirm whether the activity was carried out.

No data on the degree of implementation of these guidelines or numbers of beneficiaries of PEP have been identified.

outcome 1.4: indicators:

Create a cultural environment more favorable to preventing HIV and STI transmission

Number of Most Significant Change stories that address change in cultural environment more favorable to preventing HIV & STI transmission (M&E Plan)

Proportion of people living with HIV giving public testimonies (Prevention Plan)

Percentage of people aged 15-49 expressing accepting attitudes towards people living with HIV (Prevention Plan)

The M&E plan defines this indicator as the number of most significant change stories that are submitted to the CNLS and meet review board criteria. No system was in place to collect this information during the review pe-riod. As such, a document review of relevant documents was conducted. Data for one of the indicators — relat-ing to levels of stigma against people living with HIV — are available, and are presented in Table 3.1.18 on page 84. Once again the lack of follow-up means that it is hard to assess progress on this indicator. The results obtained during the UNICEF KAP study in 2007 are fairly consistent with those obtained during the DHS: less than half of the respondents express accepting at-titudes to people living with HIV. No data for the other two indicators were identified during the review.

outputs 1.4.1 & 1.4.2: indicators:

Promote the retention of Rwandan cultural practices that contribute to preventing HIV and STI transmission

Number of new messages targeting retention of Rwanda cultural practice that contribute to preventing HIV, STI transmission (M&E Plan)

Promote abandoning Rwandan cultural practices that contribute to the transmission of HIV and other STIs

Number of new messages targeting abandoning cultural practices that contribute to the transmission of HIV and other STIs (M&E Plan)

Number of IEC/BCC events (Prevention Plan)

The M&E plan defines these indicators as the number of new or significantly different messages which are dis-seminated in the year promoting retention of Rwanda

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cultural practices that contribute to the prevention of HIV, and promoting the abandoning of cultural practices that contribute to the transmission of HIV, respectively. As no system was established to collect this information, a review of relevant documents was con-ducted. Because the two Outputs under this Outcome are closely linked, they are dealt with together in this section. Theoretically, cultural practices that are relevant to HIV prevention or transmission could include sexual practices and attitudes, or the existence or absence of other practices (such as male circumcision and practices where there is a risk of contact with infected blood).

The relevant strategic documents (NSP, Prevention Plan, BCC guidelines) do not provide substantive infor-mation or specific examples on the cultural practices that should be promoted or eradicated under this Out-put, or on how to go about promoting or eradicating cultural practices. However, HIV-related research refers to certain practices that are related to sex (although it is not clear how common they are):

• Kunyaza (a form of sexual stimulation of female genitals before penetration, leading to wet sex)

• Gukuna imishino (labia elongation / genital modification)

• Widow “inheritance” or sexual intercourse with recent widows

Different sources disagree as to whether all of these practices actively contribute to HIV transmission, whether they help reduce transmission, or whether they are neutral. For instance, kunyaza is assumed to be a risky practice if performed without a condom; however the same can be said for penetrative sex so there is not a clear case for working to eradicate kunyaza. A recent anthropologic study has argued that labia elongation, once classified as a form of female genital mutilation, should no longer be considered as such (6). No data were identified specifically in relation to these indica-tors. Overall there is little evidence of specific initia-tives in respect of this Outcome, but it is possible that cultural practices — both negative and positive — were addressed to some extent in regular BCC/IEC programs and communication campaigns.

3.2 – Hiv pRevention: ConCLUSionS 3.2.1 – Relevance, Comprehensiveness and ScaleDuring the period under review there have been signifi-cant improvements in the delivery of a number of key HIV prevention services: the numbers of people reached

with awareness-raising programs, the provision of HIV testing, PMTCT and blood safety measures have all increased significantly compared to the situation in 2005. In addition, some indicators suggest improved effectiveness and quality of services, for instance the proportions of people testing who go on to receive re-sults, and the proportions of people testing positive who go on to receive appropriate services. Although it is still the case that more women than men receive HIV test-ing, the proportions are less divergent than they were in 2005. There has been reasonable success at implement-ing some of the policies and objectives established in or around 2005, for instance in relation to integrating PMTCT and VCT with health facilities, provider-initi-ated testing, and mass communication campaigns.

On the other hand it does not appear that progress has been made in other areas, such as condom distribu-tion (and implementation of the Condom Policy in general), moving from IEC to BCC, and strengthening prevention efforts to include sexual health (specifically STIs). In terms of moving from IEC to BCC, while there have been changes in the content of messages, it is less apparent that prevention programs have change the way in which they engage with target populations, in order to make them participants in prevention rather than simple recipients. The results of efforts to target HIV prevention programs are mixed. Notwithstanding the fairly broad definition of priority target groups, it is clear that efforts to reach young people have been suc-cessful. On the other hand, systematic targeting of sex workers and other higher risk groups in every location does not appear to have been taken place. The recom-mendations of some highly relevant studies for program targeting — such as the PLACE studies — have not been systematically acted upon.

Although knowledge of the HIV situation is stronger today than it was when the last NSP was developed, it appears nonetheless that some key factors related to targeting and prevention approaches (particularly “outreach” type activities) and regarding barriers (for instance barriers to condom use) were not fully acted on during the review period.

3.2.2 – Key Achievements and Major Challenges and GapsThe national strategy for HIV prevention: Although the HIV prevention strategy incorporates most of the key components of an evidence-based approach, it is notable that male circumcision — accompanied by

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appropriate communications around continued HIV risk for circumcised men — is not a part of the current strategy. Conversely, a number of prevention programs during the review period have included activities that do not appear within the national strategy. World Bank MAP funding in particular was used to support a large number of income-generation projects under the head-ing of HIV prevention.

There are a number of inconsistencies between the different documents that contain policy and strategic guidance for HIV prevention. However, there are some overall inconsistencies between the Prevention Plan and the NSP itself, as the Prevention Plan does not address all 14 of the NSP Prevention Outputs. For instance, the Prevention Plan provides few details on cultural practic-es that help to slow or increase the spread of HIV (Out-come 1.4) on strategies for promoting sexual responsi-bility (Output 1.1.3), and no details on approaches for ensuring delivery of post-exposure prophylaxis (Outputs 1.3.3 and 1.3.4). On the other hand, the Prevention Plan does outline an intervention that is not specifically mentioned in the NSP: regional programming designed to take into account cross-country migrations.

Another area where the prevention strategy lacks clarity is in the definition of priority target groups “at high risk of HIV infection”. The list is useful in that it segments the population into categories that can be reached in different ways — and indeed, the BCC Strategy pro-vides suggestions as to how best to reach each group. However, the list is too broad to be used as a tool for prioritizing HIV prevention interventions, as it more or less encapsulates the entire Rwandan population. Indeed, although it is impossible to avoid some degree of overlap between groups, some of the categories are broad making the degree of overlap is very high: for instance, it is highly likely for the same person to be part of the following groups: police/military; couples; and employers/employees.

Impact: None of the available data show strong evidence of increases in HIV prevalence at a national level over the period 2006-2008; however nor do they provide any evidence for decreases in HIV prevalence. Results of forthcoming ANC surveillance and DHS surveys (planned for 2009), are likely to provide a more reliable picture of whether and how prevention efforts since 2006 have affected the spread of HIV at national level. In addition, the forthcoming BSS (2009) will collect HIV prevalence data on sex workers and truck drivers.

Policies and strategies for changing high risk sexual be-havior: A number of different policy and strategy docu-ments have been developed in order to provide guid-ance for programs aimed at changing high risk sexual behavior. The documents that have been produced cover IEC/BCC, condoms, and testing. The IEC/BCC guidance to some extent includes guidance on promo-tion of sexual responsibility (Output 1.1.3). However, very little guidance is provided in relation to improving knowledge on STI, TB and OIs (Output 1.1.5), which may help to explain why this Output appears to have been relatively neglected.

Implementation of programs aimed at changing high risk sexual behavior: The different Outputs under Outcome 1.1 have been unevenly implemented, with much more emphasis being placed on Output 1.1.1 (IEC/BCC), Output 1.1.3 (promoting sexual responsibility among young people) and Output 1.1.4 (increased knowledge of HIV status) than on the other two Outputs. This may be because the content of Outputs 1.1.2 (condom promotion) and 1.1.5 (awareness of STI, TB and OI) is not well integrated into IEC/BCC and life skills educa-tion programs. Indeed, the review suggests that in gen-eral, programs aimed at reducing risky sexual behavior have been limited to providing fairly basic information on HIV transmission and prevention and on dissemi-nating messages promoting abstinence and fidelity and to a lesser extent condom use.

There is very little mass communication for condoms and that information provision on STIs and TB is at best superficial. Because messages on their own rarely effect large scale risk reduction, behavior change pro-grams should ensure that the information they provide is contextualized; they should also work to empower communities by also providing opportunities for dia-logue and reflection.

It is crucial that efforts to promote behavior change, condoms and HIV testing be matched by adequate provision of services. The results of the review also sug-gest that interventions aimed at changing risky behavior may not be sufficiently linked with improved access to condoms and services: the data collected during district field visits in particular suggest that many HIV preven-tion programs are not delivered in a way that is clearly linked with the relevant services. Conversely, the review shows that behavior change efforts as a whole have been more successful where they have been designed as a comprehensive “package”. For instance, partici-

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pants who showed the greatest openness to discussing sexuality with their children were often those who were receiving a range of other prevention services such as comprehensive information, interpersonal commu-nication, targeted condom distribution and access to clinical services.

Another important principle for behavior change pro-grams is to ensure continuity: behavior change is not a rapid process, as it takes time for communities to iden-tify the factors that create vulnerability and risk and to discover ways of addressing these factors. The results of the review indicate that in many cases, behavior change programs are implemented for a finite period of time, often due to funding constraints.

Targeting of programs aimed at changing high risk sexual behavior: The results of the review show that programs have targeted most of the “priority target groups” for HIV prevention. The available data do not provide precise indications of the extent to which each group has been covered by prevention programs. However, it is clear that the majority of effort has been focused on reaching young people, particularly those in schools. Treatment programs for people living with HIV appear to incorporate a strong HIV prevention component, in-cluding making condoms available (from Focus Group Discussions).A number of programs have reached groups that are known to have higher levels of risk behaviors and higher HIV prevalence such as sex work-ers, transporters and prisoners. However, these groups are not covered to the same extent in every location in the country: targeting of these most-at-risk groups has been inconsistent. One of the groups, people with disabilities, has barely been reached. This is particularly significant given that many people with disabilities are not able to access information and services designed for “general” population groups.

Geographical coverage of programs aimed at changing high risk sexual behavior: The field visits carried out in selected districts as part of the review provided strong indications that HIV prevention programs are still largely focused on urban centers. Even where IEC/BCC are provided outside of urban centers, rural populations still have very limited access to condoms and testing. Members of the prevention technical working group stated that the problems with geographical coverage are not only about rural sites being underserved, but also about some remote districts being underserved by funders and implementing agencies.

Changing behavior of health personnel: In general, the information available suggests that considerable efforts have been expended to train health care workers on universal precautions and blood safety. The indicators selected for tracking injection and universal precautions practice are not optimal: for instance, the “percentage of facilities where the team is practicing safe injections” simply divides facilities according to whether they do or do not practice safe injection, instead of tracking rates of injection safety within each facility and if necessary tracking why those rates are not at 100%. Data on HIV testing for TB cases are encouraging; on the other hand no concrete conclusions can be drawn in relation to the treatment of STIs and referral of STI patients for HIV testing. However, it is a common impression among key informants that levels of STI treatment are not optimal.

Medical prophylaxis: Because of the lack of data, the only conclusions that can be drawn relate to the PMTCT program. The steady increase in the number of facilities offering PMTCT is encouraging. Also en-couraging are the increases in the percentage of part-ners of pregnant women agreeing to undergo testing, given the probable contribution that HIV transmission between stable partners makes to the spread of HIV in Rwanda. However, some important challenges have been identified in relation to case identification and fol-low up of pregnant women testing positive for HIV and their children.

Cultural Practices: The cultural practices that should be abandoned or promoted under this Outcome are not clearly defined, making it difficult to assess the extent to which cultural practices have been addressed. The rela-tionship between some practices and HIV transmission are not entirely clear: so for instance, although some aspects of kunyaza (if practiced without a condom) may contribute to increased risk, but it may also reduce risk in other ways (for instance, avoidance of dry sex). Hence, classifying practices according to whether they should be promoted or abandoned may be too simplis-tic. The DHS data on acceptance of people living with HIV indicate that levels of stigma may still be fairly high in Rwanda.

3.2.3 – Key RecommendationsEnsure that strategies are evidence-based and that they are implemented fully: The review has indicated that HIV prevention strategies have not always been implemented in a comprehensive way. Hence, behavior change programs have often stopped at the provision of basic

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information and instructions on behaviors to adopt, rather than supporting individuals and communities to better understand sexual and reproductive health and the threat of HIV and to use this understanding to find ways of reducing their own risk. Similarly, efforts to increase use of condoms have not been sufficiently supported by activities to promote greater acceptance of condoms. And although promotion of the principle of parent-child dialogue on sexuality has been widespread, many parents do not have the knowledge or skills to talk to their children, and many children feel unable to admit that they are sexually active to their parents.For some of the strategies that have been supported, such as income generation activities for HIV prevention, there is still very little evidence of their impact on HIV transmission at national level. The effectiveness of “ab-stinence only” promotion programs has also been called into question by recent research (37). On the other hand, a new strategic plan should consider the inclu-sion of additional strategies which have been shown to be effective for HIV prevention. Male circumcision is one key example.

Address the causes of stigma: Stigma and denial have played a central role in the spread of HIV. HIV stigma largely originates from societal reactions to the fact that HIV is sexually transmitted. Hence, it is difficult to tackle HIV stigma while maintaining judgmental attitudes to sex, because when sexual activity is seen as shameful or immoral, people are reluctant to openly seek HIV prevention advice, information and services. The review has shown that stigma and shame is not just attached to HIV, but it is related to sexual activity in general, and also to STIs. People can also be stigmatized for other reasons, for instance because they are poorly educated, because they have tuberculosis, etc. Getting detailed information and services is particularly chal-lenging for young people who are told they are supposed to abstain from sex, because many young people are sexually active and most will become sexually active at some stage. HIV prevention programs in Rwanda need to intensify efforts to promote open dialogue around sexuality, sexual health and HIV and to challenge ap-proaches that risk creating further stigma and denial.

Provide HIV prevention services and interventions as a comprehensive “package”: To be effective, HIV preven-tion programs need to deliver a “package” of different interventions or services rather than focusing on one intervention such as BCC, condom promotion, or male circumcision. At implementation level, HIV prevention

programs should be designed with this in mind, so that the different interventions and services are interlinked and so that there are strong referral mechanisms: for in-stance between IEC/BCC and STI treatment, condom provision and HIV testing services. Many implement-ing organizations do not have the capacity to deliver all of the different services: in these cases they should work with other organizations to plan how best to deliver the comprehensive “package” that is required. National pre-vention policies should outline the importance of this approach; however, to be implemented effectively, effec-tive mechanisms for planning HIV prevention inter-ventions and services at district and sector levels are also required. At implementation level, it is also important that strong linkages be made between the HIV preven-tion “package” and care, treatment and impact mitiga-tion programs so that they are mutually reinforcing.

Ensure continuity of HIV prevention interventions and services: If ensuring that people are well informed was all that was required to reduce HIV transmission, it would be possible to deliver HIV prevention interven-tions in a one-off way. However, many of the interven-tions and services people need to protect themselves from HIV need to be continuously available – espe-cially condoms and STI treatment. Behavior change communication should also be provided in a continu-ous way as peoples’ attitudes and circumstances change over time. People very seldom “choose” one preventive behavior that they stick to forever: a person who has abstained for sex for some time needs to know how to protect themselves when they become sexually active.

Ensure that intensive prevention programs primarily reach most-at-risk groups, while continuing to implement broader strategies for the general population: Although it is important that everyone in Rwanda has equal access to basic information and services such as HIV testing and condoms, there is undoubtedly a case for targeting specific HIV prevention programs to certain groups who are at highest risk. The current list of priority target groups captures almost the entire population of Rwan-da, it does not help HIV prevention programs to target the groups that are key to the progression of HIV in Rwanda. The recently completed “triangulation” exercise provides a clearer indication of the most-at-risk groups.

In designing programs aimed at reaching most-at-risk groups programs should take into account not just the immediate behavioral risk factors, such as high numbers of partners and unsafe sex: they should also take into

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account issues such as marginalization and stigmatiza-tion which may stand in the way of these groups access-ing HIV prevention services.

Future plans should take into account geographical coverage: The data used for this review do not provide a precise picture of the level of coverage of different sec-tors and districts by HIV prevention services. However, many informants agreed that in certain districts in particular, and have been underserved by prevention efforts. Efforts should be made to ensure that basic information and services are distributed equitably throughout the country; and the results of the triangu-lation exercise should be used to identify whether any geographic zones require particular additional attention for HIV prevention efforts.

Clearly define indicators, and implementers should collect data against these indicators in a consistent manner: This review has been limited by the scarcity of consistent data over the review period. On the one hand, a number of the indicators in the M&E Plan and Prevention Plan are not clearly defined, as they do not specify how data should be disaggregated, and they do not incorporate baselines or targets. On the other hand, implementers have not been consistently tracking the core indicators, with some indicators only being tracked for one year out of the three years under review, and others being TRAC tracked in different ways by different partners.

3.3 – Hiv SURveiLLAnCe AnD ReSeARCH: pRoGReSS

3.3.1 – Impact, Outcomes, and Outputs under reviewThe strategy for HIV surveillance and research is de-scribed in axis 2 of the NSP. The Impact, three Out-comes and twelve Outputs shown in Table 3.3.1 on page 84 were under review. Indicators for each result level are presented in section 3.3.2.


impact 2 indicator

National response to HIV/AIdS is adapted to Rwanda’s conditions and surveillance/ research results

Number of strategic planning/policy documents that have references or citations of Rwanda-specific surveillance or research documents

The selected indicator to measure this impact result focuses on instances of the use of surveillance and research results in evidence-based decision making. The NSP also states that the overall strategy is to transform the results of surveillance and research into informa-tion products that are readily accessible and usable by stakeholders. As such, the Outcomes and Outputs are designed to set up systems and strategies to facilitate the use of data and information for decision making. Over the course of the review period, several strategic planning and policy documents reference surveillance and research results. Though it was not possible to comprehensively review all documents produced in Rwanda during the review period, several instances are mentioned below.

Economic Development and Poverty Reduction Strategy: The largest strategic planning exercise over the review period was the Economic Development and Poverty Reduction Strategy (EDPRS). The EDPRS elaboration process was conducted using a results-based planning and management approach, in order to define sector-specific key actions and key indicators, using baselines and five-year targets. To ensure an evidence-based approach, an AIDS Poverty Impact in Sectors Review was commissioned in May 2006 to look at the impact of HIV on each sector and collect evidence to inform planning. Although difficulties were encountered in collecting relevant sector-specific HIV information and research, the strategies were informed by existing data wherever possible. For instance, the health sector’s key indicators and targets for prevention were based on DHS data concerning HIV prevalence and related risk behavior.

Each EDPRS sector was responsible for implementing the key actions they committed to in their EDPRS logi-cal frameworks in order to attain the defined targets. Given the decentralized government structure, the ED-PRS HIV indicators and activities have been adjusted and incorporated as appropriate into the 5‐year District Development Plans (DDP) and district annual work plans (15).

Other National Strategies: Over the review period, all of the Global Fund proposals submitted by Rwanda used existing surveillance and research results to inform the proposals. DHS results were widely used for setting baselines and other studies were mentioned where appropriate. The PEPFAR Steering Committee (PSC) conducts joint planning each year with the CNLS and

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based their Country Operational Plans (COP) over the review period on the existing data. This data was used to prioritize interventions and re-orient strategies.

National Campaigns: Over the review period, surveil-lance and research results were consistently used to in-fluence national campaigns. After a review of the terms of reference for each year’s national theme for World AIDS Day, each document referenced Rwanda-specific surveillance or research results including the DHS na-tional HIV prevalence rate, the results of special studies on the uptake of VCT conducted by TRAC Plus and MOH, and recent research results on sero-discordance conducted by Projet San Francisco. In addition, na-tional mass-media campaigns including the Witegereza campaign conducted by CNLS and PSI was based on DHS and BSS behavioral data.

District Strategies: During the field visits in 11 districts, the field teams met with CDLS and other district-level HIV implementers in order to assess their use of the results of surveillance and research data in planning and decision making. All districts had seen the national prevalence rates reported in the 2005 DHS. Apart from DHS, the CDLS members had little knowledge of the results of other surveillance or research activities. The results of the 2005 sentinel surveillance studies were not known by any district. Some districts had heard of the 2005 PLACE study and one district reported shifting their strategies in terms of the results. During interviews, CDLS members reported that data is seen as something collected for reporting to the hierarchical supervisors, not something that should help them in identifying strategies at the district level.

Assessing Outcomes and Outputsoutcome 2.1 indicator

Increase the usefulness of surveillance results with respect to the national response to HIV

Number of articles submitted with a Rwandan among the first 3 authors to peer-review journals using HIV/AIdS related surveillance and/or research data results

The TWG judged that this indicator was not an ac-curate measure of the general increased usefulness of surveillance results, as the number of articles in peer-re-viewed journals provides an extremely narrow measure of the Outcome. Instead, the TWG performed a review of the dissemination mechanisms in place for the results

of surveillance activities as a first step towards increasing their usefulness. If people don’t have access to the infor-mation it cannot be used, and is therefore not useful. An increase in the dissemination of results also increases access. In order to assess the dissemination mechanisms of surveillance results, the two principal national-level sero-surveillance activities were considered: the DHS and ANC sentinel surveillance. In addition, the dis-semination mechanisms for the behavioral surveillance study (BSS) are assessed under Output 2.1.1.

The Demographic and Health Survey in Rwanda: The DHS 2005 was the first DHS in Rwanda to include HIV biomarkers in order to estimate population-based HIV sero-prevalence both nationally and across socio-demographic factors including age, sex, socio-economic status and geographic situation (urban vs. rural). After the completion of the final report, a meeting gathering all HIV implementers and development partners was or-ganized in order to share the results. In addition, a num-ber of materials, including brochures and posters, were distributed. The results and final report are all available on the MEASURE DHS website. As mentioned above, DHS data is widely used to inform national strategies and was known by all districts. The HIV prevalence cited in DHS 2005 is consistently quoted as the nation-al accepted prevalence in most documents. The results of DHS are used to inform national-level exercises, such as the National HIV/AIDS Estimates, modeled using EPP and SPECTRUM software, and the production of the annual HIV Epidemic Update.

ANC Sentinel surveillance: ANC sentinel surveillance in Rwanda is based on HIV sero-prevalence among pregnant women who attend ANC clinics in 30 health centers across the country. Since 2005, TRAC Plus has increased the number of sentinel sites from 24 to 30 in order to ensure a better geographical coverage taking into account urban, semi urban and rural areas in the new decentralized government. Surveillance data from the 30 sites are collected over a two-week period every two years and a report is produced after analysis. Over the review period, sentinel surveillance studies were conducted in 2005 and 2007.

Results of the 2005 study were disseminated in June 2007. In order to disseminate the results, a national-level workshop was organized before posting the results on the TRAC Plus website. In the districts, no CDLS members knew the results of any sentinel surveillance activities.

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The results of the 2007 study are not yet published. Like DHS, sentinel surveillance data are used to inform national-level exercises, such as the National HIV/AIDS Estimates, modeled using EPP and SPECTRUM software, and the production of the annual HIV Epi-demic Update. Other instances of the use of this data include UNGASS reporting and national level exercises such as data triangulation.


Improve national systems for case notification of morbidity and mortality related to AIdS

Percentage of all AIdS-related deaths that are reported through national health information system (SIS)

Number of medical and non-medical personnel trained to accurately determine causes of death

The TWG could not find data on the second indicator, number of medical and non-medical personnel trained. Instead, the TWG reported the number and percentage of health facilities accurately reporting AIDS-related deaths through the case notification system, as this is a better indicator of an improvement in the system. Since 2006, the Ministry of Health’s Health Informa-tion System (SIS) unit receives weekly health data from all health facilities in the country, including AIDS-related mortality data. Table 3.3.2 on page 85 shows the progression of health centers that notified AIDS-related deaths from 2005 to 2007, with nearly all health centers reporting AIDS-related deaths through the SIS by 2007. Table 3.3.3 on page 85 displays a very low rate of AIDS-related death notifications compared to the estimations of total AIDS-related deaths. Although Table 3.3.3 displays a high percentage of health centers using the SIS for case notification, fewer than 10% of AIDS-related deaths are reported through the system.


Establish a sustainable behavioral surveillance system

Annual report on behavioral change using National BSS and other behavioral studies is disseminated

Concerning the proposed indicator, no national annual reports on behavior change were produced during the reporting period. Instead the TWG assessed the overall

functioning of the existing behavioral surveillance activ-ities. TRAC Plus began behavioral surveillance activities in 2000 by creating a Behavioral Surveillance Commit-tee comprised of TRAC Plus, CNLS and other surveil-lance experts in order to track HIV behavioral trends in at-risk populations that are missed by population-based surveys such as DHS. The main activity of the Behav-ioral Surveillance Committee is the Behavioral Surveil-lance Study (BSS) which was conducted in 2000 and 2006. During 2007, the results of the BSS 2006 were disseminated through a validation workshop. The final report was posted on the TRAC Plus website and dis-seminated to relevant HIV stakeholders. The committee has now decided to implement the BSS every two years, with the next BSS being conducted in 2009.

Although the Behavioral Surveillance Committee successfully conducts BSS, the committee does not currently play a role in the coordination of other behavioral surveillance activities. This resulted in some overlap of activities over the review period. For example youth aged 15-24 were included in the BSS 2006. UNICEF conducted another BSS of youth aged 10-24 in 2007. Youth will again be covered in the BSS 2009. Several other small behavioral surveillance studies are conducted by other development partners, such as PSI and FHI. These studies are often done in conjunction with TRAC Plus.


Improve HIV sero-surveillance by including other HIV/AIdS-related diseases

National surveillance reports include prevalence of infections other than HIV

During the review period, TRAC Plus did not conduct sero-surveillance of HIV-related diseases. As part of the ANC sentinel surveillance system, syphilis data was collected from pregnant women, though this data was never analyzed or disseminated. A new department at TRAC Plus was established to conduct these activities in 2008, and should begin integrating surveillance of all STIs/OIs in 2009.


Improve the statistical and analytical competencies of surveillance technicians

Number of Rwandans involved in surveillance that are trained in statistics and data analysis

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The TWG could not find sufficient data to report on this indicator. Moreover, it was determined that the number of people trained is not an accurate indicator of an improvement in competencies, as participation in a training event does not implicitly result in improved skills. In general, there was no overall strategy for in-creasing the capacity of surveillance technicians during the review period though there were some surveillance capacity-building activities conducted in an isolated manner. Most HIV implementers organized trainings in statistics and data analysis according to their needs. For instance, before starting the data collection in the sentinel surveillance sites, TRAC Plus trained its agents on the data collection process. Annual reports from TRAC Plus and CNLS also report selected staff partici-pating in international and national trainings to build surveillance capacity.


Improve the usefulness of research results with respect to the national response to HIV/AIdS

Number of documents with reference to Rwanda-specific research or surveillance

The TWG judged that this indicator was not an ac-curate measure of the general increased usefulness of research results, as the number of documents with reference to results provides a narrow view of the situa-tion. The indicator was not well-defined as to the type of documents to review. Instead, the TWG performed a review of the dissemination mechanisms in place for research results as a first step towards increasing their usefulness. If people don’t have access to the informa-tion it cannot be used. An increase in the dissemination of results can indicate increased access.

CNLS Resource Center: The CNLS Resource Center is located at CNLS office and serves as a main mechanism to disseminate data from reports, books or research findings, and other documents related to the HIV response. The Resource Center reported a net increase in the number of visitors to the center over the review period, from about 5,800 people in 2005 to nearly 7,000 visitors in 2007. The data dissemination activities of the Resource Center include the following:

• Physical library that contains books, journals, and hard copies of research studies;

• Internet access to make the data available online to visitors to the center;

• Video archives and films available on the Rwandan HIV response; and

• Radio programs aired each Saturday to address the principal questions that are posed by callers on the CNLS HIV Hotline.

Digital library on HIV/AIDS: The Digital library is a web-based online library that has been operational since 2006. Anyone with an internet connection can access ar-chived documents through the CNLS website. Available documents are collected monthly from HIV stakehold-ers. The library’s objective is to establish a well-organized archive for available information on HIV/AIDS in order to increase dissemination and accessibility. Although the library is functional, the staff often has a difficult time to collect all data, reports and studies from all partners. Implementing partners don’t routinely provide copies of their data to the digital library and many studies are missed through this system. There is currently no link-age between the HIV/AIDS Research Committee and the Digital Library to ensure that all research protocols that pass through the committee are archived in the library. The Digital Library has also experienced some technical difficulties over the course of the review period but is planning for a technical revision in 2008.

Websites: The CNLS, TRAC Plus, MOH and most de-velopment partners disseminate the results of research, special studies and reports through their websites. All annual reports for the above-mentioned institutions were accessible through the web.

Dissemination Workshops: During key informant inter-views, most HIV stakeholders reported organizing dis-semination workshops over the review period as one of the main mechanisms for disseminating data. Reports, research and other studies are widely disseminated through these channels to HIV stakeholders within the country.

International and National Conferences: Over the review period, HIV stakeholders during key informant inter-views report active participation in both national and international conferences. Rwanda sent delegations to all the major international conferences, including the International AIDS Society Conference and the HIV Implementers Meeting. In addition, the CNLS hosts two conferences each year to increase the dissemination and exchange of research results: the Research Confer-ence and Exchange on HIV/AIDS and the Pediatric Conference. Both of these national conferences provide a venue for national and international researchers to disseminate their findings to other HIV stakeholders.

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Improve the methodological competencies of researchers

Number of Rwandans trained in research methodologies

Improve the statistical and analytical competencies of researchers

Number of Rwandan researchers that are trained in statistics and data analysis

Over the review period, there was no overall strategy from the CNLS to build the capacity of researchers. Although no overall vision existed, there were a num-ber of activities conducted by various partners. These activities however were not coordinated nor designed specifically to contribute to the achievement of these Outputs. For example, the National Ethics Committee organized trainings on research methodology and the School of Public Health, in collaboration with CNLS and Tulane University, organized trainings on HIV & AIDS-oriented research methodology. Both TRAC Plus and CNLS reported in their annual reports that several of their staff participated in various international and national trainings to improve research capacities over the review period.


Involve people to be studied in the identification, design and execution of research

Number of protocols executed that include participation of the population that is being studied

In order to ensure the implication of people being studied in the identification, design and execution of research, the HIV/AIDS Research Committee on HIV/AIDS has included this specific point as part of the ap-proval process for protocols. Researchers must address how the populations being studied are implicated in order to receive approval. In addition, the involvement of target populations is one of the main points on which the Ethics committee focuses in order to approve a submitted project. Other measures have been taken at the national level to ensure this implication. For example, a representative from the Rwandan Network of People Living with HIV/AIDS (RRP+) is a member of the HIV/AIDS Research Committee.


Improve the functioning of the HIV/AIdS Research Committee

Number of HIV-related studies approved by the HIV/AIdS Research Committee

In 2005, the CNLS created a national HIV/AIDS Research Committee with the mission to examine and approve research protocols for all organizations or indi-viduals aiming to conduct research and/or studies in all areas of HIV/AIDS, and to coordinate the overall HIV/AIDS research agenda in Rwanda. The HIV/AIDS Research Committee developed terms of reference for the committee and its members, submission forms for the approval of research protocols and a draft research guide to direct HIV research. Despite the availability of all the necessary organizing documents, the committee faces several challenges in implementation, including the availability and participation of committee mem-bers. The committee was also intended to coordinate all research projects that are done on HIV/AIDS at the national level but there is no mechanism in place to achieve this.

As a result, outside of the annual Research Conference, research agendas are not coordinated often resulting in overlap of research, as others do not know what has been previously studied. It is important to also mention the absence of research regulations at the national level, as the committee has no true jurisdiction to stop poten-tial researchers. This situation makes it more difficult for the HIV/AIDS Research Committee to coordinate. In terms of the proposed indicator, 15 research proto-cols were approved in 2006 and 41 were approved in 2007.


Improve the ability of stakeholders to interpret and use surveillance and research results

Number of Most Significant Change stories that address stakeholder ability to interpret and use surveillance and research results

This indicator could not be reported against for the review as there were never any structures put in place to collect “most significant change” stories. As a substitute for the progress of this Outcome, the results of the im-pact indicator mentioned above can provide a general

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picture of an improvement in stakeholders’ ability to use surveillance and research results. At the national level, some instances of improvements in stakeholders’ ability to use results are noted.

The EDPRS elaboration process used an approach which was based on transforming baseline data from surveillance and research into key policy actions in order to achieve a desired target, such as a reduction in prevalence among 15-24 yr olds by 0.5% in five years. The national campaigns were all designed to address problematic trends or evidence from surveillance and research results, such as the high rate of sero-discor-dance among married couples. There is no evidence to this point to demonstrate an improved ability in using results at the district level. The field visits showed that district stakeholders have very little knowledge of the results of research and surveillance, and very few districts visited during field visits could report a shift in strategies based on the use of any results (2/11).


Promote and facilitate the routine availability of surveillance and research results

Number of new research studies disseminated at the annual national research exchange conference

This indicator is not an accurate measure of the routine availability of surveillance and research results because the national research conference is limited to a specific number of abstracts that are disseminated. Instead, this result could be better measured by reviewing the above examples of dissemination mechanisms for surveillance and research results corresponding with Outcomes 2.1 and 2.2. These instances display an increase in the mechanisms for data dissemination that were developed over the course of the reporting period.

output 2.3.2 & 2.3.3 indicators

Improve the analytical capacity at all levels of beneficiaries and decision makers

Number of non-technical persons trained in data analysis and interpretation with Rwanda specific exercises or examples

Strengthen the capacity of technicians and stakeholders to present results in various more useable formats

Number of people (technical and non-technical) trained in data information presentation with Rwanda specific exercise or example

Over the review period, there was no overall strategy to build the capacity of beneficiaries, stakeholders or deci-sion makers. Although no overall vision existed, there were a number of activities conducted by various HIV implementers and stakeholders. The National Institute of Statistics implemented a capacity-building program to improve the analytical capacity of government minis-tries. They have assigned a focal point in each ministry to assist in the use of data for decision making. Dur-ing the preparations for the annual Research Confer-ence, some activities were conducted to assist potential researchers in better presenting their data for poster presentations or abstracts.

3.4 – Hiv SURveiLLAnCe AnD ReSeARCH: ConCLUSionS

3.4.1 – Relevance, Comprehensiveness and ScaleRelevance: The Outcomes and Outputs planned reflect the major gaps in the use of data and information for a more evidence-informed planning and decision mak-ing. The three Outcomes were logical and accurately addressed gaps that contributed to poor use of data and information, with an emphasis on data dissemination at all levels and building the human capacity to use infor-mation. Routinely using data and information requires a change in mentality and behavior around planning and decision making. The NSP took this into account while developing their Outcomes.

Comprehensiveness and Scale: Although major achieve-ments were made in data and information dissemina-tion, the comprehensiveness and scale of human capac-ity development activities were not sufficient. Though the plan recognized that these were key changes that needed to happen to promote the better use of data, this plan was never translated into an operational strat-egy. Isolated cases of trainings and other activities for human capacity development were recorded, but there was no overall strategy for building capacity at all levels.

3.4.2 – Key Achievements and Major Challenges and GapsData and Information Dissemination Mechanisms: The higher-level Outcomes for this strategic axis are con-cerned with strategies for improving the usefulness of the results of research and surveillance activities. As stated above, mechanisms for data dissemination are a first step in increasing the usefulness of data; as if the data is not available or accessible then it is difficult to

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improve its usefulness. Over the review period, major progress was made in developing new and different data and information dissemination mechanisms and there are several strategies now in place that did not exist in 2005. Namely, the two annual research conferences give a national platform for information dissemination and regroup all of the major HIV stakeholders twice per year to exchange results, best practices, and lessons learned. The development of an HIV/AIDS Digital Library and a physical Documentation Center are two other examples of new dissemination mechanisms that didn’t exist at the beginning of the review period. As Rwanda’s internet access continues to improve, inter-net-based mechanisms such as web-based databases and dissemination through institution websites also show net improvements in dissemination mechanisms.

Although progress has been made, there are still some gaps in the routine analysis and dissemination of data that exists. For example, the data from the Health Information System (SIS) are not analyzed or dissemi-nated. Partners who do have available information often do not provide it in a timely manner to the staff of the Documentation Center or the HIV/AIDS Digital Library, reducing the total number of documents avail-able in both institutions. In addition, the districts still reported limited access to information and very rarely, if ever, use the information that is available to inform planning and decision making.

HIV/AIDS Research Committee: One of the major single achievements in this strategic axis was the successful development of an HIV/AIDS Research Committee to assist in the coordination of national and international HIV research being conducted in Rwanda. Though the committee has some needs for capacity building moving forward, the mechanisms that have been put in place to coordinate research and promote a better ex-change among researchers nationally is certainly a large achievement over the course of the plan.

Despite this progress, the Committee still has a num-ber of challenges that they continue to face since its inception in 2006. Namely, there is no mechanism in place to collect or disseminate the results of research protocols that have been approved by the committee. Researchers pass through the committee, obtain ap-proval, and carry out their research but then never share the final results with the HIV/AIDS Research Commit-tee. Also, one of the original mandates of the Research Committee was to develop a national HIV research

agenda and coordinate its implementation. This was never done. There is still some debate as to whether this should indeed be the role of the HIV/AIDS Research Committee, but to date this is a major challenge for the committee. No clear strategy or vision for capacity building: Perhaps the largest constraint noted in this strategic axis was the general lack of strategy for build-ing capacity in research, surveillance or data use, both among technical and non-technical persons. Over 40% of the stated Outputs in the NSP for this strategic axis directly refer to capacity building activities yet no clear strategy for this capacity building was ever developed. Though a number of activities were completed in an isolated manner and there were some results to report, this was an overall major gap.

Lack of Coordination of Behavioral Surveillance: There is still no mechanism in place to coordinate the various behavioral surveillance activities being conducted by the government and non-government partners. In addition, there is no prioritized list of potential at-risk popula-tions that should be tracked through behavioral surveil-lance. The original NSP listed over 15 potential at-risk groups. These groups should have been prioritized and subsequently tracked over the review period, whether through direct national-level efforts or the coordination of non-governmental organizations’ behavioral surveil-lance activities.

3.4.3 – Key RecommendationsDevelop better mechanisms for analyzing and dissemi-nating data, particularly from national to district level: Districts reported low use of access to data and limited feedback mechanisms in place from the national to the district levels. Districts need to first have access to the different types of data/information available if they are expected to use it for decision-making at their level. One strategy for achieving this could be the better im-plication of the Documentation Center and HIV/AIDS Digital Library as mechanisms for data dissemination.

Develop a Human Capacity Development plan for staff involved in the M&E system, including surveillance and research: Although dedicated staff for surveillance and re-search may not be necessary or feasible, dedicated M&E staff that have minimum skills in data dissemination and use, including results of surveillance and research, are critical to the proper functioning of the M&E sys-tem. For example, every health center should have a data management officer for data collection, analysis and dis-semination of routine health statistics and surveillance

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and research results. In addition, strategies should be de-veloped to build the capacity of CDLS in accessing and using data for decision making and planning, including their increased participation in partner activity planning to better use of data specific to their region.

Better coordinate behavioral Surveillance activities and routinely review at-risk populations based on most recent evidence: Due to a lack of Rwanda-specific data on the actual at-risk populations in 2000, the Behavioral Sur-veillance Committee based their choice of target popu-lations on three of the WHO-recommended popula-tions most vulnerable to HIV infection: young people aged 15-24, sex workers, and truck drivers. These three risk populations were tracked in 2000 and 2006, and are planned for 2009. Given the new evidence that exists on the dynamics of HIV transmission and new infections in Rwanda, including the data triangulation project and Modes of Transmission incidence modeling, behavioral surveillance activities should be re-evaluated to ensure that we are targeting the most-at-risk groups. In addition, better coordination of behavioral surveil-lance activities other than the BSS, including defined periodicity of behavioral surveillance activities, would reduce overlap in behavioral surveillance activities con-ducted by other partners.

Review the role of the HIV/AIDS Research Committee: The role of the HIV/AIDS Research Committee in developing and coordinating a national research agenda with TRAC Plus and MOH, School of Public Health, and other research partners should be reviewed. HIV research activities are within the mandate of TRAC Plus and their individual role in coordinating HIV research should be reviewed. Regard-less of the coordination body for HIV research, mecha-nisms for collecting the results of approved research and disseminating these results in a regular manner are needed, in addition to strategies for building capacity of researchers.

3.5 – Hiv CARe AnD tReAtMent: pRoGReSS

3.5.1 – Impact, Outcomes, and Outputs under reviewThe strategy for HIV care and treatment is described in axis 3 of the NSP. The Impact, three Outcomes and eighteen Outputs shown in Table 3.5.1 on page 85 were under review. Indicators for each result level are pre-sented in section 3.5.2.


impact 3 indicator

Improve treatment, care and support for persons infected and affected by HIV/AIdS

Percentage of persons on ART that are alive 12 months after starting treatment

The HIV M&E Plan defines this indicator as the percentage of adults and children who are still receiv-ing ART — with absolute adherence — 12 months after starting treatment as a measure of both survival and adherence, with ART site reports through TRAC-net as the data source. TRACnet however currently captures aggregate site-level data and doesn’t have the capacity to calculate survival rates for an individual patient. A study conducted in 2005 however by TRAC Plus reports 91% alive at 12 months after initiation of treatment. This study has not been conducted since 2005 so no follow-up data exists to compare to this baseline. TRAC Plus reports aggregate site-level lost to follow-up rates however in their annual reports. Trends in lost to follow-up over time have slightly increased but appear to be stabilizing, as shown in Table 3.5.2 on page 85. Given this stabilizing trend and the high percentage known to be on treatment after 12 months, the data suggest that survival rates may not have signifi-cantly changed since 2005. This lost-to-follow up data however provides no information regarding adherence. Though ART patients are meant to receive adherence counseling at each monthly visit, data is not currently captured on this at the facility level.

The improvement of quality of care and treatment: During Focus Group Discussions with PLWHA on treatment, over 90% of participants strongly affirmed that ARVs had positively impacted their lives in many ways including: rapid increase of the CD4 counts and fall of the viral load, becoming stronger and dynamic than before and able to perform different duties to sustain their lives and families, return to their previous jobs after long time of absence.


Increase access to high quality care and treatment at health facilities

Percentage of males and females with advanced HIV/AIdS infection receiving ARV combination therapy

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This indicator is defined in the M&E plan as the percentage of, or estimated number of, advanced stage HIV+ people who are receiving ART. This was assessed by calculating the number of patients on ART out of the estimated number of patients in need of ART (i.e. with advanced HIV/AIDS infection) annually from 2005 to 2007. The number of patients on ART is from TRAC Plus annual reports. The number of patients in need of ART was estimated using the SPECTRUM sta-tistical package. Table 3.5.3 on page 86 shows that not only has there been an increase in the absolute number of people on ART over the entire NSP period, the over-all coverage for ART treatment nearly doubled from 2005 to 2007. This increase corresponds with the scale-up of ART sites in the country (see Output 3.1.1). This historical trend, combined with the absolute number of patients on treatment from Jan-June 2008 suggests that the coverage percentage for 2008 will increase.


Assure equitable coverage of ART services with emphasis on pediatric care

Percentage of health care and other facilities that are treating HIV+ infants and adults according to national norms and procedures

The M&E Plan defines this indicator as the percent-age of all public and para-public health facilities (FOSA) which treat HIV+ infants and adults accord-ing to national standards and procedures. The data source is cited as TRAC Plus annual reports. Under this Output, progress was assessed by reviewing the overall percentage of health facilities providing ART services as our measure of coverage, and the availability of ART guidelines at the facilities as our measure of treatment according to national norms and procedures. Throughout the NSP period, the percentage of health facilities providing ARV treatment increased (see Table 3.5.4 on page 86). The increase in coverage of ART sites certainly contributed to the increased number of people on treatment over the review period. Though no disaggregate site-level data was available for urban/rural comparisons, anecdotal data from TRAC Plus suggests that scale-up is planned equally in urban and rural sites.

Since 2005, ART guidelines have been available in all health facilities providing ART services. TRAC Plus conducts quarterly supervision with all ART sites to ensure that they are up to date and following current guidelines.


Improve treatment of OI according to national norms and procedures

Percentage of all service providers trained in diagnosis and treatment of OI according to national guidelines

This indicator is defined in the M&E plan as the percentage of all appropriate service providers the have been trained 5 or more days in diagnosis and treatment of OI according to the national protocol. Though an intervention monitoring database housed as CNLS is cited as the data source for this indicator, no such data-base was designed during the NSP period thus an alter-native strategy to assess progress was developed. Under this output, progress was assessed by first determining the availability of OI services guidelines in health facili-ties and calculating the number of health personnel trained to deliver OI services according to guidelines as our measures of progress. Though accurate data wasn’t available for analyzing trends in health worker trainings, overall over 700 health personnel from health clinics, PMTCT sites and ART sites participated in trainings on quality improvement of OI services

There were no specific OI guidelines designed during the NSP period. In 2003, guidelines were drafted for all infectious diseases, including OI, which were in use throughout the review period. TRAC Plus is currently drafting new and specific OI guidelines for all health facilities. During focus group discussions, a majority of participants stated that they are often transferred to district hospitals because health centers are not always stocked with the necessary drugs for OI treatment.


Reduce the real cost of accessing HIV/AIdS related care and treatment

Percentage of people that are TB+ who receive TB therapy

This indicator is defined in the M&E plan as the percent of, or estimated number of, TB+ people who received TB therapy during the 12 months reporting period. The data source cited is TRAC Plus annual reports. During technical review meetings however the TWG felt that the proxy indicator proposed was not relevant to measuring a reduction in real cost. The TWG felt it was more accurate to review some of the major initiatives in reducing the real cost of accessing services. Though the definition of the term “real cost”

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was not clearly defined in the NSP, several activities were carried out throughout the review period to reduce the cost of accessing HIV/AIDS related services.

The establishment of the community based health insurance (CBHI) scheme offered at health centers has greatly contributed to the reduction of the real cost of treatment for many PLWHA, as described in Output 3.1.7. The increase in ART sites during the review period also brought services closer to beneficiaries and reduced travel time to treatment sites. In addition, in-creased availability of community-based care (outreach programs) has brought services to the community level.

During the focus group discussions, about 40% of the participants stated that they still have problems related to the cost of accessing ART and related services. Some of the costs mentioned are the co-payments (300 FRW) made every time a patient visits the clinic. Other cost problems mentioned were indirect costs. For example, when a patient visits a clinic and spends half or whole day with no food left at home for children and cost of losing time from work.


Promote approach “Provider Initiated diagnosis (PId)”

Percentage of all service providers trained in diagnosis and treatment of PId according to national guidelines

This indicator is defined in the M&E plan as the percentage of all appropriate service providers the have been trained 5 or more days in PID according to the national protocol. Though an intervention monitoring database housed as CNLS is cited as the data source for this indicator, no such database was designed during the NSP period thus an alternative strategy to assess progress was developed. Though the Output directly states “provider initiated diagnosis”, the current policy is now referred to as “provider initiated testing” (PIT). The goal of initiating PIT was to increase the number of people tested in a health facility setting as an entry point for ART. The strategies to achieve the Output in the NSP included the development of directives to private, public, and affiliated health facilities.

At the end of 2005, the approach PIT was still new in Rwanda. By 2007, TRAC Plus began drafting PIT guidelines for all health facilities. These guidelines are still currently being developed. Implementation of PIT

in all health facilities may cause some personnel prob-lems, as PIT increases the workload of service providers. This general issue is currently being addressed however as the MOH plans to roll-out task shifting strategies at all facilities. At district level, during site visits to health facilities in rural and urban districts about PIT, there were low levels of service providers aware of the ap-proach PIT, though most stated they have been practic-ing similar guidelines, though without formal direc-tives. About 30% of providers said they know about PIT, but don’t practice it systematically and requested guidelines and training.


Improve collaboration and service referrals between health care providers and community agents

Number of joint sessions/meetings between medical corps and community health care providers

This indicator is defined in the M&E plan as the number of joint sessions/meetings between medical corps (of FOSA employees) and community health care providers (non-medical corps). CDLS and DHT reports are cited as the data source. After a review of CDLS reports it was determined that this indicator is not something that is routinely reported by CDLS thus an alternative strategy to measure progress was developed. As the MOH is now responsible for the integration of community health services, stakeholder interviews were held with key experts in the Commu-nity Health Development department of MOH as well as interviews with non-public organizations working in community health.

The MOH Community Health Development Depart-ment coordinates the collaboration between commu-nity health agents and health facilities. The system was established so that community agents could liaise with health personnel to facilitate delivery of HIV/AIDS care. It was also planned that community agents be ac-tively engaged in the psychosocial and spiritual support of PLWHA to improve quality of treatment in the com-munity. Community health workers who are engaged in the delivery of the home based care services are basically volunteers. They are given stipend/incentives for trans-port to attend meetings and to deliver monthly reports to health facilities. In 2007, the MOH worked closely with the USG-funded CHAMP project to finalize the “linkage model”

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for increased community and facility coordination. Partners in Health (PIH) is another organization that has been heavily engaged into HIV/AIDS community-based care services. PIH is currently working in four districts of the eastern province and one district in the Northern Province. Their activities are aimed at im-proving rural health care through training and engaging community health agents who help in the delivery of the HIV/AIDS related services including ARV treat-ment. This year, the community health department under MOH is planning to standardize and harmonize packages of services for the CHW.


Improve therapeutic nutritional support for people on ART

Number of FOSA with capacity to provide nutrition therapy as part of in-patient support to HIV/AIdS patients

The M&E plan defines this indicator as the number of health facilities with the necessary equipment, sup-plies, budget and trained personnel to provide thera-peutic nutrition according to established norms. The plan further cites the CNLS intervention monitoring database and information from MOH and districts on budgets, plans and equipment as primary data sources. The CNLS intervention monitoring database was not developed during the review period. In addition, no systems were established for the routine reporting on budgets, plans and equipment dedicated to therapeutic nutrition services. A review of all health facility budgets and equipment lists was out of the scope of this review. As such, the progress of this output was measured by reviewing annual reports for TRAC Plus and other de-velopment partners involved in nutritional therapy. Key stakeholder interviews were conducted with public and private-sector stakeholders and beneficiaries.

In the NSP, it was planned that all patients on ART should have access to proper nutrition to enhance ART pharmacological effects and facilitate better drug ab-sorption. Little is however said on strategies to achieve the Output. In 2005 when the NSP started, the revi-sion of policy on nutritional support for People on ART was still in progress and pilot trainings on nutritional management of people infected and affected by HIV/AIDS, infants born to HIV+ mothers were conducted. The policy was adopted in 2006 and further roll-out of trainings for health personnel were conducted. By 2007, about 90 adults and 168 infants benefited from

nutritional support. 86 health workers were trained on HIV/AID nutrition, care and support at community levels. In the NGO sector, CHAMP supported its implementing organizations to provide various types of assistance related to nutritional support for PLWHA. Namely, the CHAMP-supported health facilities were supported with food for exposed infants under five to protect them from malnutrition; and 950 households received nutrition support in 11 districts.

Nutritional therapy is still problematic according to officials in the MOH in charge of community health development. During key informant interviews, MOH staff reported that every development partner has a different package, and there is a lack of national data on the number of households receiving food support in the community, making it difficult to assess overall progress.

We also wanted to have some views from beneficiaries of nutritional support (PLWHA on ARVs). We were interested in knowing the type of support they receive, if the support is enough, and how it has positively im-pacted their lives. In the eastern province where PIH is operating, there seems to be no problem with accessing nutritional support and package size. All beneficiaries (focus group with 12 participants) reported that the ARV and food package has been very helpful and had positively impacted their lives. All the participants in the focus group said they have good treatment adher-ence and more energy to return to their work and sup-port their families. On the contrary, in other provinces, depending on the partner, the food package is varying and often insufficient and it is given for a short time.


Integrate care and treatment of OI among other illnesses supported through Community based Health Insurance (CBHI)

Percentage of community health insurance providers (mutuelles de santé) that have included OI in the list of illnesses covered.

The M&E Plan defines this indicator as the percentage of all number of mutual health insurance societies that have included OI among the list of insured illnesses. The data source cited is MOH ad-hoc reports. MOH produced no ad-hoc reports on this over the review pe-riod thus a document review of existing documents was conducted. In addition, key informant interviews were held with PLWHA and health personnel at the district

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level. The NSP does not clearly outline strategies to achieve the Output. It says that patients need to have improved access to OI services by overcoming financial barriers which limit the service use. In 2005, not all OI were covered under the CBHI. In mid 2006, all OI illnesses were “integrated” into health care services and diseases covered under CBHI. By early 2008, all OI were covered along with other illnesses covered under CBHI.

During field visit, we were interested in knowing if OI services had been fully integrated and if beneficiaries can truly access these services without barriers. All the health providers we talked to revealed that OI are fully “integrated” into CBHI. However, the providers said that even though OI drugs are officially provided under CBHI coverage, there are still barriers to access, in-cluding the lack of trained staff at facilities to properly diagnose and prescribe drugs for OIs and frequent stock outs of some drugs. Health workers from both rural and urban districts shared the view that they do not receive detailed training on the OI manuals.


Strengthen health care provider’s capacity to deliver highest quality of care

Percentage of all employees working at FOSA trained in quality assurance

The M&E plan defines this indicator as the percent-age of all employees at health facilities that have been trained 5+ days in one or more components of quality assurance. The plan further cites the CNLS interven-tion monitoring database as the primary data source. The CNLS intervention monitoring database was not developed during the review period. As such a literature review was conducted for relevant information and key informant interviews were held with TRAC Plus and MOH personnel.

In 2005 when the NSP started, different types of train-ings aimed at improving capacity to provide quality HIV-related services. Over the review period, TRAC Plus continued to train staff on quality service delivery, participate in workshops and conferences related to quality assurance, and update policies and guidelines to include quality-assurance strategies. By 2007 several different types of quality assurance trainings were being conducted by TRAC Plus during supervision visits to health facilities and district hospitals. Trainings were

held on quality assurance of TB, early infant diagnosis, and VCT/PMTCT/ART integrated services. By 2008, approximately 75% of doctors in all 30 districts ben-efited from TB/HIV integration trainings and nearly 200 health personnel were trained in the integration of quality VCT/PMTCT/ART and TB services.

Key informant interviews were held at the quality as-surance department at MOH to get more perspective on quality improvement initiatives. Officials reported in that MOH treats quality improvement in broader sense covering all health sectors including HIV/AIDS, making it difficult to exactly identify issues related to quality improvement in HIV/AIDS care. Addition-ally, officials in charge of strengthening capacity in the MOH (in-service training and recruitment) supported this finding. Speaking with officials from TRAC Plus, we were informed that training is done but not to its full capacity. There are no targets on number of staff to train as there is no systematic capacity building plan. Even though significant number of health workers in HIV/AIDS area might have been trained, it is hard to quantify what has been done to strengthen health care providers' capacity to deliver highest quality of care over the entire NSP period.


Increase access to high quality community-based care and treatment

Percentage of eligible households that receive Rwanda’s minimum package (or more) of community-based services in their home

The M&E plan defines this indicator as the percentage of eligible households identified by community FBOs and umbrella organizations receiving at least Rwanda’s minimum package of home-based HIV/AIDS services. The plan further cites the CNLS intervention monitor-ing database as the primary data source. In addition, no routine monitoring system was established for reporting on numbers of eligible households identified by com-munity FBOs and umbrella organizations. No relevant information was found in reviewing annual reports or other documents. Another major challenge in assess-ing any progress is the lack of a standard definition of “high quality community-based care and treatment” in any planning or other strategic documents. The CNLS intervention monitoring database was not developed during the review period. As such a literature review was conducted for relevant information and key infor-

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mant interviews were held with TRAC Plus and MOH personnel and NGO-sector stakeholders involved in community-based services.

According to officials from the MOH’s department of community development desk, care and treatment at the community level is implemented by two organiza-tions namely: PIH and CHAMP. Since 2006, PIH started using the system of engaging trained commu-nity agents to deliver ARVs and basic care associated with HIV/AIDS. PIH is implementing this system in four districts of the Eastern province and one district in the Northern Province. CHAMP mainly focuses on care and does this through palliative care in the com-munity by engaging community agents and partner organizations who are their implementing agents in the USG supported sites. Some CHW in other areas have been providing HIV/AIDS preventive services in the community. By January 2008, comprehensive policy guidelines were drafted and the community health development desk is in the process of integrating and harmonizing the packages of care for all the partners intervening in nutritional programs.

Throughout the review period, however there has been remarkable progress in engaging community health workers (CHW) in the delivery of HIV/AIDS and other health care services. In 2005-2006, the system of community health workers (CHW) covering each vil-lage (umudugudu) in all the districts of Rwanda was put in place (one village can contain about 50-150 house-holds and each village is supervised by 2 CHW- a man and a woman). The CHW are democratically elected at the community level by the population in village catchment zone. CHW are generally volunteers but the government supports them through incentive structures like performance based financing on certain activities (e.g. number of pregnant women, TB suspected cases, cataracts, and women referred to the health facility for delivery).


Assure equitable coverage of community-based care and treatment services

Percentage of administrative sectors in which home-based care is provided

The M&E plan defines this indicator as the percent-age of all administrative sectors in which home-based care is provided as reported by implementers to CDLS. The cited data source, CDLS reports, however did not

include information on this indicator after document review. Measuring equitable coverage for community based care and treatment services can only be effectively assessed if the following is known:

• Number of people on ART in need of community based care and treatment services;

• Minimum package of care required for the home-based care; and

• Number of partners providing minimum community based care and treatment services.

At present, it is difficult to establish how many people on ART are in need of community-based care and treat-ment services, as the criteria to identify people in need have not yet been finalized. As well, the description of a harmonized minimum package of care and treatment at the community level has still to be publicized through the guidelines soon to be produced by MOH. Partners provide different packages of services for community based care covering different areas and for different periods. According to a key informant from the Com-munity health development desk (MOH), it has been difficult to track, harmonize and coordinate all the part-ners providing nutritional support. Considering these different elements, it is impossible at the present time to assess the progress and results achieved for this Output.


Improve the community-based care and treatment of people living with HIV/AIdS (medical, psychosocial and spiritual)

Number of HIV+ people assisted in their homes for ART adherence

The M&E plan defines this indicator as the number of HIV+ people on ARV who are assisted with Adherence (DOT) in their homes. The cited data source, CDLS reports, however did not include information on this indicator after document review. As such a literature review was conducted of all relevant documents and key informant interviews were conducted with MOH and TRAC Plus personnel.

Strategies for improving community-based care and treatment were mainly restricted to the improvement of community-based nutritional support services and pediatric follow-up. Over the review period protocols were developed for delivering nutritional therapy at the community level to PLWHA and some health person-nel received training on community-based nutritional support. This also led to improved communication

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and coordination between associations of PLWHA and health facilities in their catchment areas.

The most important achievements during this period however concern community pediatric follow up. Several strategies for early infant diagnosis and mentor-ing systems for infants were implemented during the review period. This involved improved counseling and follow-up, coordinated between facilities and commu-nities. Health workers were trained and informed about follow-up norms for children and monthly reports on the number of infants lost to follow up were produced to track trends. As a result of these strategies 2,533 infants referred by the community turned up for early infant diagnosis, with nearly 60% of infants tested. About 12% of all tested infants were HIV+ and thus referred for ART treatment.


Strengthen the technical capacity of people and organizations providing care and support

Number of people trained in techniques for HIV/AIdS home-based care

The M&E plan defines this indicator as the number of non-medical people completing 5 or more days of training in techniques for HIV/AIDS home-based care techniques during 12 month reporting period. The plan further cites the CNLS intervention monitor-ing database as the primary data source which wasn’t developed. As such a literature review was conducted of all relevant documents. Though a number of capacity-building activities were conducted for health personnel over the review period, almost none of these train-ings were focused on non-medical personnel. The few exceptions are linked to the improvement of nutritional therapy at the community level described in several different Outputs above. Similarly, national representa-tives of PLWHA were trained on basic nutritional needs in order to maximize treatment outcomes. In addition, nursing school teachers were trained on nutritional management of PLWHA with advanced illnesses.


Integrate home-based care and treatment for PLWHA within community-based health services

Number of homes visited by trained MOH health visitor’s program [Now known as Community Health Workers, or Agents de Santé)] agents for HIV/AIdS related care.

The M&E plan defines this indicator as the number of homes visited more than 12 times by MOH commu-nity health agents- trained in HIV/AIDS home-based care during a 12 month reporting period. The plan cites the CNLS intervention monitoring database as the pri-mary data source, which wasn’t developed. In addition, CDLS reports did not include routine reporting infor-mation on households consecutively visited in a given period. As such relevant documents were reviewed and key informant interviews were held with MOH and TRAC Plus personnel and other NGO-sector service providers.

Throughout the NSP period, basic HIV/AIDS preven-tive services were integrated into existing home-based care services. Home-based care organizations such as CHAMP started home based care and support for PLWHA under the program of RPO (Rwanda partner organizations). RPOs work with associations of CHW and PLWHA in the community. CHW help to con-duct home visits for the bed ridden patients and also to deliver other essential materials for the PLWHA in their homes.

In general, community-based organizations are not well coordinated in terms of strategies and implementation of community based care and treatment (determining size of package, reporting system, harmonization and geographical coverage). The community health develop-ment desk is working on integrating and harmonizing the community based care package (nutritional pack-age, policy, norms and guidelines, incentive structures, role and responsibilities, areas of intervention and geographical coverage) with all stakeholders.


develop and standardize out-patient and mobile treatment services

Number of rural administrative sectors visited by mobile treatment units that adhere to national standards and protocols

The M&E plan defined this indicator as the number of rural administrative sectors visited by mobile treat-ment units that adhere to national standards and protocols. CDLS reports are cited as the data source for this indicator. After document review however it was determined that no routine reporting systems were es-tablished for this indicator. As such, relevant documents were consulted and key informant interviews were held with TRAC Plus staff. Throughout the review period,

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the out-patient and mobile treatment services were not developed. A TRAC Plus official declared that the Out-put was never developed since there had been increased access to the ART sites in most parts of the country. The official asserted that out-patient and mobile treat-ment system tend to produce poor outcomes because the clients are not as effectively followed up. The only institution that developed and implemented out-patient and mobile treatment is the army because of the way the institution is functioning. As not all health facilities in need of ART have received them, this has been given national priority over the development of out-patient and mobile treatment services.


Improve the nutritional status of people infected and affected by HIV/AIdS

Number of homes of PLWHA that are provided with nutritional and/or food security support

The M&E Plan defines this indicator as the number of homes of PLWHA which are provided with food and nutrition counseling and/or assistance with growing and preparing foods and/or school feeding programs. No data source is cited for this indicator. As such, rel-evant documents were reviewed. Throughout the review period, there was generally an increase in the number of organizations providing nutritional support, though no national policy was put in place. Some of the organiza-tions providing nutritional support include CHAMP, PIH, World Vision, World Relief, WFP, CARITAS and ICYUZUZO.


Assure that HIV/AIdS related care and treatment is sustainable

Number of objectives in the national sustainability plan that are reached

The M&E plan defines this indicator as the number of objectives specified in the national sustainability plan that are reached during each reporting year and cumulative through the review period, citing CNLS annual reports as the primary data source. During the review period, there were no specific national sus-tainability plans developed for HIV/AIDS activities. However, there were some activities carried out that can translate into a sustainable treatment, care and sup-port for PLWHA. These activities include the creation of associations and the small scale income generating

activities among the PLWHA. Because the govern-ment of Rwanda is pushing the transformation of these associations into cooperatives, it is believed that once all the associations have completely transformed into cooperatives, some sustainability levels will be achieved if they benefit from continued technical support. Other strategies that were successfully implemented and ensured efficient delivery of care and treatment include improving financial accessibility to care and treat-ment for PLWHA through CBHI system (Mutuelles de Santé) and motivating health personnel to provide high quality care through performance based financ-ing (PBF) of health services. Already in place in district hospitals and for some activities in health centers, this financing mechanism motivates health staff to improve the quality of its efforts for high quality care provision, as they can receive a salary supplement for achieving targeted results.


Improve the decentralized HIV/AIdS related procurement, management and distribution system

Number of FOSA that report no stock-outs for ARV or AZT or OI

The M&E plan defines this indicator as the number of facilities (FOSA) reporting no stock outs of three drugs- ARV or AZT or Cotrimoxazole measured through FOSA reports and TRACnet. In general the procure-ment system was decentralized over the review period. TRACnet began operating in 2005 at decentralized levels to assist in the early reporting so that there is a timely response from central levels. The decentralization for care and treatment for HIV/AIDS services improved in 2006 due to increases in number of facilities provid-ing ART. In addition the creation of committees for quantification, projection, and regular checks on the state of stock for ARV and OI products at decentralized levels were routinely put in place.


Increase Rwandan human resources needed for HIV/AIdS-related care and treatment

Number of health care providers at FOSA qualified to provide AIdS, OI or STI treatment

The M&E plan defines this indicator as the number of health care providers at health facilities (FOSA) who are authorized to provide- and are providing- treat-

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ment in AIDS, OI or STI, as measured through MOH and district reports. No thorough review as such was established as part of the MOH routine reporting system and a thorough assessment of this was out of the scope of this review. As such, relevant documents were consulted. Though no disaggregated or site-level data were available, anecdotal findings from TRAC Plus and MOH annual reports indicate that there was an increase in the number of health workers trained to deliver quality services, both by the public sector and development partners such as FHI, EGPAF and IntraHealth.


Establish system to supply communities with required materials

Number of administrative sectors reporting no stock-outs of home-based care kits.

The M&E plan defines this indicator as the number of administrative sectors which report no stock outs of home-based care kits, as measured through reporting in CDLS annual reports. As such relevant documents were consulted. Though no government program exists to systematically distribute home-based care kits to communities, different materials are supplied by some development partners. For example, in CHAMP sup-ported areas, CHW who are actively involved in follow-up of bed-ridden HIV/AIDS patients are given specific kits required for palliative care. The CHW in PIH are also facilitated with kits and incentives to provide HIV/AIDS home-based care services.


Execute a national plan to assure that the expanded global care and treatment is sustainable

Percentage of activities in the annual operation plan of the national sustainability plan that are completed

The M&E plan defined this indicator as the percent-age of all planned activities in the annual operational plan of the national sustainability plan which were completed during a 12 month reporting period, as measured through CNLS reports. Though no explicit sustainability plans were developed, the CNLS de-veloped a policy document with activities outlined to ensure that HIV/AIDS interventions are sustainable, including the creation of small scale income generating activities especially for people infected and affected by HIV/AIDS, and food security programs for increasing

agricultural and livestock production and organiza-tion of trading activities. These activities have generally been implemented only at the local level depending on development partners active in the region and not on a national scale.

3.6 – Hiv CARe AnD tReAtMent: ConCLUSionS

3.6.1 – Relevance, Comprehensiveness and ScaleRelevance: In general, HIV care and treatment out-comes as elaborated in the NSP aimed to significantly increase the quantity and quality of HIV care and treatment services delivered at the facility and com-munity levels, which encompasses the major goals of the care and treatment program. Increasing access to ART services should have been the focus of the care and treatment policy during this period and several success-ful initiatives have set TRAC Plus on target to continue in achieving high levels of coverage for ART services in the future.

Comprehensiveness and Scale: In terms of the quantity of services delivered at the facility level, substantial advances were made in increasing the coverage of health facilities provided ART services, and in meeting the unmet need for ART which was reduced by nearly half in just three years. Systems were put in place for improving the quality of services by institutionalizing quality assurance teams in both TRAC Plus and MOH and in establishing a formal supervision system for all facilities. The community-based system also improved over the review period, with the implementation of the community health worker program and the technical assistance of some development partners focusing on community-based health systems and linkages with health facilities. Though interventions are underway, no routine reporting system has yet been established which would allow for an accurate assessment of increases in access or quality to these types of services.

3.6.2 – Key Achievements and Major Challenges and GapsImproved access to ART: The absolute number of patients enrolled in the ART program increased tremendously from around 19,000 adults in children on treatment in 2005 to more than 56,000 at the end of June 2008. Increases in the percentage of facilities offering ARV ser-vices from 23% to 47% were also observed. The rates of lost to follow up also seem to have stabilized since 2005.

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Community-based Health Insurance (Mutuelle de Santé): MOH reports that nearly 80% of the target popula-tion is now covered by the community-based health insurance scheme and interviews with PLWHA seem to indicate that this population has particularly ben-efited though there are still some barriers to access. At the national level, MOH assured that OI services were included into other services packages offered by CBHI. This has resulted in significant reductions in the real cost of accessing ARV services by PLWHA.

Nutritional therapy: Many strategies were implemented during the review period to increase the quantity and quality of services providing nutritional therapy at the facility and community levels. Guidelines and protocols were developed and national trainings were rolled out at all levels. Despite the achievements made, the assess-ment of coverage of the nutritional support services across the country is difficult to carry out as there is still lack of integration and harmonization of partners working in same field and the identification of people in need is problematic. This is largely due to the lack of a common definition of the standard components of a minimum package of nutritional support services.

Insufficient personnel and equip to accommodate the increasing demand for HIV/AIDS services: Many of the challenges that were found with the provision of any services, whether it be nutritional therapy, ART ser-vices or OI diagnosis and treatment, were linked to inadequate numbers of staff at health facilities, and in some cases insufficient equipment to meet demand. For example, on average there is only one person in charge of nutrition and one person in charge of distribution of drugs in health facilities. Insufficient personnel in charge of supervision at the central level contribute to the slow roll out of quality assurance strategies in all fa-cilities. In addition it was observed that one of the main barriers to full treatment of OI is the availability of doctors to adequately diagnose and prescribe treatment. Staff at the central level also reported shortages of quali-fied staff contributing to problems in monitoring ARV resistance and routine follow up of pediatric patients.

Pediatric care not adequately addressed: Though pediatric care services were highlighted in the NSP there was not significant progress observed in assuring adequate coverage of comprehensive pediatric services. Though there were some successful strategies, such as the follow up of HIV exposed infants at the community level, a more robust package of services including nutritional

support and counseling services were not integrated in general care services.

Challenges of decentralizing HIV/AIDS services: Fre-quent stock outs due to untimely reporting between CAMERWA, districts, TRAC PLUS and health staff at facility level were noted through document review and key informant interviews. The lack of quantification and projection knowledge for assessing the needs before getting into was cited as one cause of problems in addi-tion to insufficient personnel at decentralized levels to analyze, project and request the needed commodities from the central level. In addition, the new program of integrating OI drugs by the CBHI faces implementa-tion difficulties because of delays in drug distribution to health centers, and consequently to patients. The decentralization of HIV/AIDS services has the poten-tial to cause confusion on the roles and responsibilities between TRAC Plus and MOH staff.

3.6.3 – Key Recommendations Reinforce pediatric care: Further emphasis and strategies should be put into strengthening the delivery of quality HIV pediatric care services. This involves integrat-ing pediatric services into routine HIV care settings and developing standardized packages of services for pediatric HIV patients. Linkages between communities and facilities should also be reinforced to expand early infant diagnosis programs.

Continue to draft new guidelines and update existing guidelines as new information and techniques are de-veloped and adopted: Guidelines for PIT for example should be developed and disseminated as soon as pos-sible to increase the number of people tested for HIV as an entry into the care and treatment program. Proto-cols for OI diagnosis and management should also be revised taking into consideration MOH’s new strategies for task shifting at all levels.

Develop strategies to address the insufficient personnel needs at facilities and the lack of qualified staff: Some strate-gies such as task shifting to solve problems of human resource shortages should alleviate the problem some-what. The recruitment of more qualified health work-ers and strengthening the in-service training program through supervision visits should be explored.

Minimum package of services: There is a need to develop standard minimum packages of services so that health

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facilities and development partners have a common understanding of the services that are meant to be provided to specific subpopulations. This will include drafting and disseminating clear guidelines for all partners working in the community and home-based care field. Emphasis should be put on developing clear targets and strategies to ensure that needed community-based materials are effectively supplied.

3.7 – MitiGAtinG tHe SoCio-eConoMiC iMpACt DUe to Hiv/AiDS: pRoGReSS

3.7.1 – Impacts, Outcomes and Outputs in 2005 designed to address the situationThe strategy for the mitigation of the socio-economic impact of HIV is described in axis 4 of the NSP. The Impact, three Outcomes and eleven Outputs shown in Table 3.7.1 on page 86 were under review. Indicators for each result level are presented in section 3.7.2.


impact 4 indicator

Mitigate the socio-economic impact of HIV/AIdS

Increase in GdP

The M&E plan defines this indicator as the mar-ket value of all final goods and services produced in Rwanda during the 12 month reporting period, as measured by MINECOFIN. The indicator used for this impact result is obviously much wider than the direct measure of how HIV activities influence the global eco-nomic situation in Rwanda. Having said that, we were not able to obtain documentation on this economic indicator’s evolution between 2005 and 2008; the only qualitative information pointing to a stabilization of the economic situation, but not a clear improvement in the socio-economic status of the general population. It is therefore impossible to draw definitive conclusions about this impact result, relying more on the results at outcome level to give a general picture of the evolution in this axis.

The slackening in GDP growth is the result of the expansion of output in agriculture being constrained by several factors. Land is scarce and the use of it is con-strained by the absence of a well-defined land admin-istration system and poor settlement patterns in rural areas. There is a need to contain the fragmentation and

degradation of further arable land as a result of high pressure and soil erosion. The level of technology is low, infrastructure in rural areas is inadequate and hu-man and physical capital is in short supply. As a result, agricultural productivity is low which generates poor returns on private investment.


Improve the socio-economic conditions in Rwanda (and assure vulnerable groups benefit as much as others)

Per capita income

The M&E plan defines this as the total income divided by the total population, as reported in MINECOFIN reports. The same comment made about the impact in-dicator also applies to the income indicator: per capita income of the general population is a poor indicator of the socio-economic status of the vulnerable groups. As indicated above also, we did not obtain data on the evolution of per capita income during the period.

The most up-to-date information on per capita income as a measure of improved socio-economic conditions is derived from the 2005 EDPRS strategic document. According to this document, the incidence of consump-tion poverty has fallen in both rural and urban areas since 2000/01. The extreme poverty line represents the level of expenditure needed to provide minimum food requirements of 2,100 kcal per adult per day. More than one-third of the population is unable to achieve this level of consumption and consequently go hungry. The upper poverty line includes non-food requirements and over half of the population remains unable to provide for these basic needs. The average poor person’s consumption is at about RWF 150 per day and has only increased by 2% in the past five years.

Rates of poverty reduction since 2000 have been mod-est and are not fast enough to meet either the targets set in Vision 2020 or the MDGs. The total number of poor people has now increased to five million. Over 90% of poor people still live in rural areas.


Create employment opportunities in particular for vulnerable groups

Percentage of vulnerable people (members of associations of PLWHA ) who are unemployed

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The M&E plan defines this indicator as the percent-age of vulnerable people who are unemployed. It cites ad-hoc reports from RRP+ and MINALOC as the data source. After the document review, no information on this indicator was included in institutional reports. As such, the TWG chose to assess the progress in the num-ber of PLWHA supported by IGA micro projects.

As shown in Table 3.7.2 on page 87, there is a steady progression in the funds allocated to IGA micro-proj-ects from 2004 to 2007, with a relatively proportional increase in the number of micro-projects and in the number of beneficiaries. The data for 2008 is incom-plete but also reflects a slowing down in the funds allocated by the main donors in this field as the strat-egy for economic enhancement was being revised. The CNLS/ MAP, CNLS/PNUD/BAD, PEPFAR and Care International were the main funding agencies for those projects. The contribution by MAP makes up 88.3% of the total funds allocated to the micro-projects.

Interviews with key partners and implementers at the national level were also conducted to gather their opin-ions about the income-generating activities by PLWHA associations/cooperatives’ members. They mentioned good practices by associations/cooperatives that they funded: cooperative’s members manage to get together for an income-generating activity, do small businesses, accept their status, and give their testimonies; all that with the fund they had from IGA. Implementers affirm to be fully satisfied of the beneficiaries’ life conditions and of their standard in the society comparably to the time before the funding, even if there is still an unsatis-fied need for that target group.

In focus group discussions, more than 85.7 % of beneficiary groups (meaning 12 focus groups out of 14) confirm that with funding received from income-generating projects, PLHIV found again self-confidence and a new hope to live longer. They learned how to do savings, how to improve their life conditions, how to lower stigma and discrimination, how to keep on with ARV treatment program and how to keep their family living.

Lessons learned from assessment reports (CNLS/PNUD, CHAMP): These data are drawn from a preliminary report on the assessment of socio-economic impact of micro-projects funded by CNLS/PNUD project. This study aimed at analyzing the outcomes from income-generating micro-projects funded by the above men-

tioned project for the families infected and affected by HIV as well as the impact remarked at the level of their insertion area (March 2008). In regard to the improve-ment, the increase of vulnerable groups’ income and the sustainability of those projects through job and other IGA creation, 61 by 84 assessed micro-projects work better and have provided an average money income of 16,771 Rwf per capita on the total of 6,392 beneficia-ries. On the other hand, the study proved that there is a gap in their accounting system.

As far as impact analysis and social benefits durabil-ity are concerned, the study showed that the funding of micro-projects has a positive impact on PLHA lives in the sense of stimulation of their contribution in fighting AIDS; if we consider the number of PLHA who have broken the silence and who join associations willingly. The study also assessed the viability of those micro-projects as well as their impact on individuals and on beneficiary household: in terms of the improve-ment on accessibility to basic social services (education, nutrition, health care, accommodation and welfare in general), lessening of stigma and discrimination towards people living with HIV, and beneficiaries’ behavior change.

A second relevant study is the recent assessment by CHAMP on PLHA income-generating activities that are funded by CHAMP programs. This assess-ment aimed at improving the approaches adopted by CHAMP and its partner organizations for IGA, evalu-ating and analyzing durability and efficiency of ongoing IGA so as to increase income and presenting constraints and proposed recommendations/solutions to overcome them. The report concludes that in terms of support for IGAs, limited markets provide less profit perspectives for cooperatives and recommends the focus on produc-tion activities that respond to the market needs and on cooperatives’ capacity building to identify and assess market opportunities; and to develop businesses.


Assure access to credit for vulnerable groups

# of new loans given to vulnerable people (PLHIV)

total value of new loans given to vulnerable people (PLHIV)

The M&E plan defines this indicator as the number of new loans given for income generating activities to vulnerable people (members of associations of PLWHA)

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during the reporting period, and the total value of those loans. The plan cites RRP+ annual reports as the data source for both indicators. After review of such reports, it was noted that no data on this indicator were being collected. As such, the review of the progress of this indicator is limited to the documentation of some initiatives taken in that sense.

PLHA and OVC are financially supported by small income-generating credits thanks to stock deposit in credit and saving cooperatives. Through partners meet-ings and focus group discussions to explore PLHA’s experience in credit request processes, we documented some experiences of PLHA cooperatives that received credit from financial institutions thanks to stocks deposit by partners (Gasabo District with World vision (Vision Finance) and Nyagatare District with Care International). For other visited districts where vulner-able people don’t have that opportunity, beneficiaries reported that they didn’t have access to credit and that is a great obstacle to their economic development. According to the evaluation of the PLHA associations’ income-generating activities supported by CHAMP in 2008, there are many potential partners and a variety of products that are based on access to credit. How-ever, micro-finance institutions in Rwanda seem to be reluctant in risk-taking and adoption of good practices because they view PLHIV associations as high-risk groups and PLHIV are considered as unable to pay the market-oriented interest rates. In order for PLHA cooperatives to develop economically and to overcome that dependency in a sustainable way, the following recommendations were formulated: the creation of a stock deposit (guaranty fund) for PLHA and the col-laboration between financial institutions and partners (Projects that fund cooperatives).


Improve the equity and equality between women and men regarding income generating activities and employment opportunities

Female to male ratio of all grants and loans given to PLWHIV for income generating activities given to PLWHIV

The M&E plan defines this indicator as the total value of grants and loans given to female PLWHA as a ratio of the total value given to male PLWHA for income generating activities in a reporting period. CDLS reports were the cited data source though this indicator

wasn’t reported in such reports after a document review. As such, it was not possible to gather comprehensive data on gender differentiation in relation to funding of income-generating activities especially as many reports only produce general statistics on cooperatives/associa-tions’ members without sex disaggregation.

We were able to find partial data regarding funds al-located to community micro-projects by CNLS/MAP and CNLS/PNUD projects: in 2005, beneficiaries in-cluded 790 males and 2051 females while orphans and other vulnerable children were 1726. Likewise in 2007, where funded micro-projects directly benefited to 7,306 people (1,581 men, 3,264 women, 2,464 youth/chil-dren). According to partial data from RRP+, women make up 70% of the PLHIV associations’ membership and receive a proportionate share of profits from IGA.


Improve access to formal and informal education for target groups with an accent on PLWHIV and OVC

Number of OVC and PLWHA supported to attend schools or receive vocational or literacy training

The M&E plan defines this indicator as the number of OVC and PLWHA given material or financial sup-port to attend secondary school, vocational training or literary programs. Though CDLS reports were the cited data source, this indicator was not reported on after a document review. Relevant documents were thus con-sulted in addition to interviews with key informants. The support to orphans and other vulnerable children towards accessing education has markedly increased from 2004 to 2007 (see Table 3.7.3 on page 87), the variation in the number of supported OVCs being related to variable content of support package from different partners. Data for 2008 is incomplete. The main funding agencies are CNLS/MAP, CNLS/PNUD, CNLS/BAD, PEPFAR, and the Global Fund.

During field visits, 7 focus group discussions around the theme of OVC’s schooling confirmed that OVCs got significant support for their education and voca-tional training. However, there are some education-related needs for OVC’s that are still not covered. The following recommendations came out of these discus-sion groups: more CNLS involvement in the identi-fication of OVCs; better support to more OVCs and improvement on service package; and better facilitation

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for children heading households to access secondary studies while keeping on supporting their brothers and sisters for a better occupation in the future.


defend and promote human rights

Number of cases that come to court claiming violation of human rights with respect to HIV/AIdS

The M&E plan defines this indicator as the number of cases that come to court claiming violation of human rights with respect to HIV/AIDS have been used. The plan cites the Prosecutor General’s office as the data source. There is no system in place to compile the judicial cases related to protection of human rights of people living with HIV. The strategy in this domain has been to ensure that PLHA benefit from the same legal protection as other members of society, and are not discriminated against or marginalized because of their HIV status.


Improve the judicial environment for PLWHIV and OVC

Number of laws revised, adopted or repealed to ensure that OVC and/or PLWHA rights are respected

The M&E plan defines this indicator as the number of laws revised, adopted or repealed to ensure that OVC and/or PLWHA rights are respected according to the government office gazette from the Prime Minister’s office. If this gazette is still in circulation no copies or recollection of it were found. As such, the progress for this output was measured by relevant document review and key informant interview. In general, the PLWHA legal environment is difficult and there are very few services in this domain. According to HARURUKA association’s report published in 2006, women and children who seek assistance from Haguruka associa-tion get counseling and guidance of a legal nature. The most destitute people were assisted both at the level of administrative and legal authorities, and when necessary they benefit from a financial support. In the same frame of idea, socio-legal assistance was given to more than 50,000 men and children. Around 30% of beneficiaries got their cases closed.

A Legal consultation office in Rubavu District was started in early 2007. With only a few months of activi-ties in the districts, achievements are already remark-

able including the following: advice on human rights, legal guidance and consultation, payment of fees for lawyers who represent people in the court of law, radio programs on human rights at Rubavu community radio (right to life, right to education, etc.), organization of awareness raising sessions to PLWHA about their rights, in collaboration with RRP+ coordinators, counseling and guidance to victims of sexual violence (between 15-20 rape cases), awareness raising to local govern-ment leaders on fighting against discrimination, and the creation of a more efficient collaboration mechanism between local government leaders and the prosecution authority, (Trained and sensitized people at the com-munity and sectors level).

At least 10 groups among 14 discussion groups (i.e., more than 71.4%) that were conducted with benefi-ciaries in the districts assert that they know where to go for assistance when they are in trouble, discrimina-tion has decreased, beneficiaries feel respected, they have access on services and on job opportunities, raped people are accompanied as far as to the health center and receive a psychosocial support. There is an efficient collaboration between health service providers, the police and local authorities for protection of OVCs and PLWHA’s rights. However, they don’t have enough information on human rights. Many OVCs and PLWH know neither their rights nor legal procedures in case of violation of their rights. Some recommendations in this domain include trainings in human rights for OVCs in particular, the creation of mobilization teams on human rights and the enhancement of the collaboration system between health service providers, local authorities and the police (Task force for regular consultation).


Increase the number of employers who have adopted or adapted work place policies that take into account PLWHIV

Cumulative number of large enterprises and companies which have adopted HIV/AIdS work-place policies and programs for the first time.

The M&E plan defines this indicator as the cumulative number of large enterprises and companies which have adopted HIV/AIDS work-place policies and programs for the first time. A work plan policy/program should include 1) the promotion of VCT, 2) provision or pay-ment for ART, 3) prevention 4) non-discrimination, and 5) workplace action plan. The plan cited APP-

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ELAS, the public sector umbrella organization, as the data source.

As a result of efforts from APPELAS during the review period in 2005 and 2006, the following enterprises ad-opted the internal workplace policy on fighting against HIV/AIDS: BRALIRWA, SORAS, COGEAR, CAISSE SOCIALE, SONARWA, BNR (Banque Nationale du Rwanda), Banque de Kigali (B.K), BRD, BCR, FIN-ABANQUE, B.P (Banque populaire), MAGERWA, Rwanda Revenue Authority (RRA), et Electrogaz, RAR (Régie des Aéroports du Rwanda), EMUGECO (Build-ing Enterprise) RWANDAFOAM , SAKIRWA, TO-RIRWA, MILLES COLLINES Hotel, Novotel Hotel, OKAPI Hotel, SERENA Hotel, OCIR THE, OCIR CAFE, CIMERWA, SULFO, UTEXRWA, CIMER-WA, ORINFOR, RWANDATEL, RWANDASEL, GARSEC, INTERSEC, KK SECURITY. The Private Sector and APELAS that supported the implementation of workplace programs in these organizations was dis-solved however in 2008 and put under the supervision of the PSF which is now restructuring the new umbrel-las. This explains the reduction in activities in the area during the year 2007-2008.

As an example of these successes, the BRALIRWA brewery in Rubavu district has had an HIV program since 2002, with 11,000 to 12,000 people including their family members, targeted for service. The prin-cipal target groups are the transporters and marketing officers. Main activities in the prevention program include the following: organization of awareness raising campaigns on HIV prevention, VCT services, and con-dom accessibility. According to BRALIRWA, the main results of the program are as follows: after an awareness raising campaign activity, many people came for VCT; an observed reduction of absenteeism on work; and 100% treatment and care to PLWHA.


Protect young girls and women from domestic and sexual violence as well as sexual harassment

Number of cases of violence reported to local law enforcement agencies

The M&E plan defines this indicator as the number of cases of violence reported to local law enforcement agencies. Violence included is rape, sexual harassment, assault and battery. Ad-hoc reports from the Ministry of Internal Affairs are cited as the data source. These

reports however couldn’t be obtained so a document review of relevant documents and key informant interviews were conducted. Poverty and economic dependence make up very important factors of violence towards women and children. The situation of women who are victims of violence and of all kinds of abuses was showed by different studies and reports of national institutions for human rights protection and the Na-tional Police. Most cases of violence against women and girls are qualified as domestic violence.

According to the findings of DHS 2005, 35% of women have somehow experienced domestic violence acts; being physical, emotional or sexual. In addition 10% of women declared to have experienced violence actions while they were pregnant. Similarly a report published by HAGURUKA in 2006 showed a lack of a mechanism to protect women and children, victims of high-risk violence. On a total number of 415 women and children decease cases, there are 120 women mur-ders and 75 children murders due to domestic violence among spouses, parents and their children.

A survey conducted with 304 victims of rape by the Ministry of Family and Woman’s Promotion in collabo-ration with UNICEF in 2005 showed that the Rwan-dan government did not keep quiet in front of such a frightening situation. It manages no efforts in seeking a solution through laws, policies and strategies in line with the protection of women against gender-based violence. It has already set up:

• The National Policy on violence towards women and children MIGEPROF, May 2007. This policy aims at preventing and eradicate all kinds of violence towards women and children.

• National Policy on Reproductive Health which incriminates rape, especially rape against children below the age of criminal responsibility, and domestic violence. The policy makes it clear that authors of those kinds of violence are to be penalized by the law.

• Law project on prevention and regression of gender-based violence (in adoption process by the Rwandan parliament). It specifies that gender-based violence is considered as a crime and gives precision on the sanctions against it.

Community policing: The police have had very interest-ing initiatives in line with fighting against violence and crimes, in general, and the violence towards women in particular. The establishment of the Gender Desk at the

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Rwanda National Police with the support of UNIFEM that has the main objectives to facilitate GBV victims’ access to the police, to raise awareness of policeper-sons, judges and local government leaders on GBV and human rights, to improve legal support and access to counseling services in partnership with associations for the promotion of women’s rights as well as to improve rape victims’ access to expert opinion by a doctor.

Data from the Rwanda National Police report 2006 and 2007 show 2,368 cases of violence among which 68% are young people who were under 18 years of age and 32% are above 18 years of age. One example of a good practice came from SAVE THE CHILDREN in Gicumbi district (Northern Province). The project works especially in the area of children’s protection by preventing sexual violence. They have put in place community-based structures that allowed a noticeable lessening of rape cases in all sectors of the district. In 2006, there was 7 rape cases, in 2007, 78 cases and in 2008, 35 cases. The project put in place a structure named Nkundabana in which adult volunteers in care of children who had no chance to have adults in their households. That strategy is based on the community structure from cell to district level where they report all rape cases and children’s ill-treatment. There have been a training of trainers and the trainees conducted an awareness-raising session in the community.

The results from all the 14 discussion groups assert that there are many achievements in the framework of protection of women’s and young girls’ rights against sexual and domestic violence as well as against sexual harassment ; i.e. that they supported what we found in the literature review : legal support, access to counseling services through partners ( many mentioned HAGU-RUKA as the organization that provides that support especially in Kigali City) and access to medical expert opinion by victims of rape through associations that promote women’s rights.


Improve operational policies, norms and procedures to assure equitable access to services for PLWHA and OVCs

Number of operational policy documents revised or adopted that specifically address issues of equity for PLWHA and OVCs

The M&E plan defines this indicator as the number of operational government policy documents revised

or adopted to specifically address issues of equity for PLWHA and OVC. The data sources were reports from MOH, NGOs and the public sector. This informa-tion wasn’t readily available in these reports and thus a relevant document review and key informant interviews were conducted. In the area of children’s rights protec-tion during the study’s time frame, the Rwandan gov-ernment has set up a number of policies and programs. The National Policy on Social Protection (2005) that provides a guidance towards reducing vulnerability, pro-moting social risk management, coordinating foresight-edness actions and protecting vulnerable groups.

The Strategic Plan for Orphans and other Vulnerable Children (2007-2011) includes:

• Awareness raising activities for children, parents, care givers, service providers and the entire population on all the OVCs problems

• Information campaigns on HIV & AIDS and on reproductive health.

• Research on identification of OVCs so as to design well-adapted programs and actions for them.

• Putting in place/review of laws, procedures and regulations to implement programs that are keen on OVCs’ rights.

• The putting in place of community support structures for the protection of OVCs, the monitoring and service provision.

• The implementers’ capacity building in service provision to OVCs.

• Establishment of coordination mechanisms.

Finally, there are no laws specific to PLWHA, but they have access to different services: Health insurance (Mu-tuelles de santé), Education, Jobs (via different donors’ funds to IGA in their cooperative), and legal services (as cited above).


Strengthen decision making capacities of associations involved in HIV/AIdS notably through the concept of GIPA (Greater Involvement of People living with HIV/AIdS)

Number of organizations including PLWHA in their policy/planning development and program assessment.

The M&E plan defines this indicator as the number of non-HIV/AIDS organizations which have included a PLWHA association or HIV-infected person in devel-

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opment of their policies, plans and/or program as-sessments. RRP+ reports are cited as the primary data source. After document review, this information is not reported in RRP+ reports. The GIPA concept aims at involving PLWH in all decision-making processes that are in regard to interventions designed for them.


Strengthen managerial capacity of associations involved with HIV/AIdS

The number of association members trained for 5+ days on management of HIV/AIdS interventions

The M&E plan defines this indicator as the number of members of associations involved with HIV/AIDS who completed training in management for more than 5 days during the reporting period. The plan cites the CNLS intervention monitoring database as the pri-mary data source, which wasn’t developed to capture this type of information. As such relevant documents were reviewed and key informant interviews were held. Only a small number of PLWHA associations/coopera-tives’ members attended trainings on orientation to cooperatives, accounting management, micro-project designing and management, or organizing and plan-ning for activities to fight against HIV/AIDS. Despite the trainings, CHAMP and CNLS/PNUD evaluations show that associations/cooperatives remain weak, less organized and in need of capacity building in coopera-tive management.

Since 2005, PLWH and community-based youth lead-ers have been trained on a number of topics among which the following ten areas were identified as being priorities: general knowledge on HIV & AIDS, re-productive health, micro-projects, gender and HIV & AIDS, planning, monitoring and evaluation, behavior change communication, basic health, advocacy and leadership, and accounting and market bid.

Over 75% of interviewed people on the specific theme of income-generating activities, i.e. 6 / 8 districts confirm that there is: less profitability of their IGA, less participants’ capacity in project designing and manage-ment despite their being trained (the training was not adapted to the level of the target population), need of follow up for the associations’ durability; and monitor-ing of IGA by partners to ensure their sustainability. To conclude, the associations/cooperatives management capacity remain weak despite the training attended.

It was recommended that training be enhanced in the domains of projects designing and management, leader-ship and financial management.


Balance of the composition of HIV/AIdS related associations (increase proportion of male, middle class and HIV-members).

Percentage of members of associations of PLWHIV with secondary school diploma or more

Percentage of members of associations of PLWHA not HIV+

The M&E plan defines thes indicators as the percentage of new members who had secondary school education or more at the time of joining, during the reporting period, and the percentage of new registered members in PLWHA associations during the reporting period, respectively. Both indicators cite RRP+ membership records as the primary data source, though RRP+ cur-rently don’t collect adequate membership records on all members. Thus, relevant document review and key informant interviews were conducted. There are 25,128 HIV-negative people compared to 61,709 HIV-positive people comprising the total of 86,837 members of the 1,304 PLWH associations gathered in RRP+, represent-ing 29% of all members.

Though no exact estimates exist, RRP+ estimates that approximately 5% of members have at least a second-ary school education. Detailed data however do exist in three districts: Rwamagana, Nyamasheke, and Rusizi. There are 2,578 men (30.2%) and 5,953 women, for a total of 8,531 members. Among these members, 1,779 men (29.7%) and 4,207 women are HIV+, for a total of 5,986 PLWHA (approximately 70% of membership).


Increase involvement of PLWHIV in the planning, execution and review of programs

# of associations of PLWHA involved in the planning, implementation, and review of programs/projects

The M&E plan defines this indicator as the number of associations of PLWHA association members who were involved in the planning, implementation, and/or review of programs or projects during the reporting period, with RRP+ reports cited as the data source. The

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involvement of PLWHA in the planning, implementa-tion and programs review processes is evident in the sense that there is a representation at the sector’s level, an executive committee at the district level made of 7 people and a board of directors at the national level that is composed of 7 people as well. The PLWHA coopera-tives confirm members’ equal voice on profit and/or loss, public accountability in management, protection by the law on cooperatives, existence of a PLWH com-mittee at the sector’s and the district levels. However, they have a representation system that works well from the local to the national level.


Promote transformation of PLWHIV associations into cooperatives

Number and percentage of PLWHIV associations that have transformed into cooperatives

There are 526 PLWHA associations that were turned into cooperatives out of a total of 1,304 associations. Generally, they account for 86,837 members among which 61,709 are PLWHA. The transformation of associations into cooperatives brought improvements in the general functioning of associations, even if no many changes were realized at the economic level. Some people think that the operation is very expensive and complex. So, it would be necessary to clarify the regula-tion in order to respond to the vulnerable populations’ needs.

3.8 – iMpACt MitiGAtion: ConCLUSionS

3.8.1 – Relevance, Comprehensiveness and ScaleSocio-economic activities: The support of IGA for PLWHIV associations has little impact on the global economic situation of the country, so that any improve-ment or deterioration of the national economy situ-ation can hardly be linked to these local and limited micro-economic interventions. This in no way dimin-ishes the relevance of these interventions, but questions the causal link between the interventions planned and implemented and the expected outcome result (increase in the GNP).

As far as adequacy of these activities in achieving the expected results (Outcome and Outputs), several aspects are questionable: management capacity of the beneficiary associations, size of the micro projects in terms of expected impact on the economic status of the

beneficiaries and productivity of the IGAs, effective-ness of monitoring and technical assistance mechanisms for a sound implementation of these micro projects. The economic impact of these micro projects are often considered as minimal or absent, whereas the social impact is generally acknowledged (improved social integration and self-respect as productive members of their communities).

Human rights: The design of policy documents and legal framework for the protection of PLWHIV and OVCs’ human rights has made considerable progress during the period of the NSP, but what is less obvious is the degree to which these policies and laws have been put into practice and therefore to what extent they have had an impact on the quality of life of these vulnerable groups.

One can think in particular about the laws to punish sexual violence, where the mechanisms of reporting and prosecution of perpetrators is still a relatively rare practice, probably because of social norms and preju-dices that deter victims from soliciting legal assistance. Access to public services such as Mutuelles de Santee for health services and free education for all primary school students and some secondary school students are major achievements that have meaningful impact on the qual-ity of life of vulnerable groups that are characteristically marginalized when it comes to access to services.

Participation in decision making: The relevance of capac-ity building for improvement of managerial capacities as a strategy to improve participation to decision mak-ing process is clear, as well as the need for a represen-tation network to give a voice to the members desig-nated to express the preoccupations and needs of their associations.

There is however a question about the impact of these trainings, as the managerial capacities in the PLWHIV associations remain one of the main obstacles to the efficient implementation of IGAs. Is it a problem of the number of people that have been trained, or rather one of the adequacy and utilization of the competen-cies transmitted during these training sessions? And for the representative structure of RRP+, to what extent do those elected representatives taking part in the decision making bodies at district and national level really trans-mit the viewpoints of their constituency? Cooperatives formation had not been planned at the time of design of the NSP but became a national priority in 2007. The

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logic behind this policy is clear, but again, the institu-tional and organizational of many of these cooperatives is very limited, thereby threatening their viability and productivity.

3.8.2 – Key Achievements and Major Gaps and ChallengesImprovement of socio-economic conditions: In spite of the enormous needs for economic support in a country where 65% of the population is under the level of pov-erty, the IGA funded through the micro project mecha-nisms of various projects (MAP, GF, CHAMP, CNLS/UNDP/ADB) have helped a large number of PLWHIV associations to initiate or strengthen collective projects that have had profound effects on their livelihoods, more so in terms of decreased stigmatization and social isolation than in terms of economic status per se.

The majority of beneficiaries of these IGA are women, reflecting their participation in associations where they represent about 70% of all members. The substantial support to OVCs for access to education is also a major achievement of the last few years and will help to de-crease the vulnerability of these children and youths.

Human Rights Protection and Promotion: Important steps have been made in the establishment of an enabling environment for legal and policy framework for the protection of PLWHIV and OVC’s rights and for prevention and prosecution of sexual violence (list of official documents). Access to numerous services for vulnerable groups (PLWHIV, OVCs) has also signifi-cantly improved during this period: access to health services (Mutuelles de Sante), education, social protec-tion and legal services through various projects.

Participation of PLWHA in decision making: RRP+ has considerably strengthened its coordination mecha-nisms during the period of the NSP with the setting up of district coordinators in half of the districts and the strengthening of its central staff for coordination and M&E purposes. The delegation of representation from the grassroots level to the national level ensures

the participation of the decentralized structures and of local communities in the planning, implementa-tion and evaluation of activities concerning PLWHA associations/cooperatives. The transformation of the associations into cooperatives is also a mechanism to ensure fuller participation of members into the decision making process of the organization: well established rules for the functioning of the cooperatives describe clearly the transparency and inclusiveness that must be respected in distribution of profits from the organiza-tion’s activities and in decisions about the management of these activities.

3.8.3 – Key RecommendationsIGA: There is a need to focus on production activities that respond to the market needs and on cooperatives’ capacity building to identify and assess market opportu-nities; and to develop businesses.

Governance: Emphasis should be put on reinforc-ing training on project designing and management, leadership, financial management and cooperative organization.

Cooperatives: There is a need to better clarify the regula-tion to respond to the vulnerable people’s needs and to support partners in their organizational capacity build-ing and improvement of their business performances. This includes the following activities: to advocate so that implementers fund IGA; promote sustainable actions such as access to credit, to markets and to technical support; support cooperatives’ IGAs; train cooperatives on management and good governance; and improve cooperatives’ capacities to identify and evaluate market opportunities.

Legal protection: There is a need to expand legal protec-tion activities. Strategies include training in human rights for OVCs in particular, creation of mobiliza-tion teams on human rights, and improvements in the collaboration system between health service providers, local authorities and the police (Task force for regular consultation).

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4. Joint Review finDinGS: CRoSS-CUttinG iSSUeS

4.1 – pLAnninG AnD CooRDinAtion

4.1.1 – Impact, Outcomes, and Outputs under reviewThe strategy for the coordination and monitoring and evaluation of the national HIV response is described in axis 5 of the NSP. The Impact, five Outcomes and nineteen Outputs shown in Table 4.1.1 on page 87 were under review. Indicators for each result level are presented in section 4.1.2.


impact 5 indicator

Coordinate the multi-sector response for increased cost-effectiveness

The ratio of the value of government expenditures on HIV/AIdS to value of external assistance for HIV/AIdS

The M&E plan defines this indicator as the ration of the adjusted value of government expenditures on HIV/AIDS to value of external assistance for HIV/AIDS. The adjusted value of government expenditures is deter-mined by applying average external assistance values for human resources to government human resources. No data source was indicated except that the measurement should be outsourced.

This indicator was abandoned because it does not permit the measurement of effectiveness and efficiency of multi-sectoral coordination. Instead the degree of achievement of this impact result was assessed through the results of the Outcomes and Outputs below. From a qualitative perspective, during the period under assess-ment, CNLS and the other coordinating bodies of the national HIV response have put in place a coordinating mechanism to harmonize planning and M&E systems of all HIV implementers. This coordinating mechanism is an important tool to have a global overview of all the HIV interventions and improve the effectiveness and efficiency of the response.


Improve the capacities of national HIV/AIdS coordination structures

Number of MSC stories that address capacity of national HIV/AIdS coordination structures

The M&E plan defines this indicator as Most Signifi-cant Change stories that are submitted to CNLS and meet review board criteria, as assessed by the CNLS Most Significant Change (MSC) Unit. As no MSC unit was established at CNLS and no routine reporting sys-tems were put in place for this indicator, progress under this Outcome was assessed by analyzing the capacity-building activities within each coordination structure (CDLS, Umbrellas, CNLS), according to the results of the UNAIDS-sponsored Country Harmonization and Alignment Tool (CHAT) exercise in April 2008.

CDLS: District AIDS Control Committee (CDLS) are established in all Districts of the country, under the au-thority of the District Mayor and composed of Direc-tors of Administrative Units, members of the local civil society, including PLWHA, and a Technical Assistant (TA) in charge of Planning, Coordination, Monitor-ing and Evaluation. The latter is the person in charge of daily management of HIV/AIDS activities at the district level on behalf of the Mayor. In 2007 a second CDLS TA was appointed to CDLS by the Ministry of Public Service and Labor in order to strengthen the coordination of HIV/AIDS activities.

In 2006 and 2007, the two CDLS TA were trained on a semi-annual basis on the following topics: the coordina-tion and planning mechanisms for the NSP implemen-tation period, planning and reporting tools, manage-ment of the CNLS national database on HIV which enables the CDLS TAs to send data from the district to CNLS for analysis, and leadership and managerial capacity. The CDLS financial capacity in the area of the coordination of HIV/AIDS activities in districts was provided by CNLS during the review period with the support of World Bank (MAP Project), ADB, UNDP and UNAIDS. Some ongoing capacity-related chal-

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lenges for CDLS TAs identified by the CHAT exercise include a lack of capacity for resource mobilization (e.g. proposal writing for funding), weak capacity for M&E at district levels, and lack of final decision making authority.

Umbrellas: Capacity-building interventions for umbrel-las to coordinate activities of their respective sectors were built into planning and reporting activities. This capacity building in the use of planning and coordina-tion tools was extended to implementers who are mem-bers of umbrellas. These coordination structures, more independent from CNLS than CDLS, because of their statute as civil society’s representatives, participate in all conferences and training programs, both within the country and abroad, through funds mobilization from various national, regional and international partners.

However, not all of them possess the capacity to mo-bilize funds for project proposals or result-oriented ac-tion. This weakness was revealed after the closing of the MAP and the progressive withdrawal of ADB Project (in process of completion). These projects were man-aged by CNLS and funded the umbrellas’ coordination plans.

The decentralization of these umbrellas is not effective in all districts, which makes the coordination of their sectors difficult and very often umbrellas are unable to complete the planned annual activities and to attain expected annual results of their sector. Two evalua-tions in the area of building the capacity of umbrellas to coordinate and evaluate HIV/AIDS activities were carried out in 2007 and 2008 (CHAT Report). The major capacity-related challenges include limited M&E capacity and week coordination and communication structures from national to district levels.

CNLS: The main achievements of CNLS as the central coordinating body of the national HIV response are documented in the CHAT report. The main recom-mendations included in the CHAT report are presented in Table 4.1.2 on page 88.

The issues identified by the CHAT report suggest that there are three priority actions needed:

• There is need to accelerate the process of integrating HIV/AIDS as a cross-cutting issue.

• There is need to strengthen capacity of technical assistants at district level to ensure their coordination and monitoring and evaluation role.

• International partners need (a) more transparency in allocation of resources, (b) to align their M&E systems to the national system, and (c) to participate actively in the various working groups.


V.1.1 Strengthen leadership capacity of personnel

Number of members of coordination structures, trained in leadership skills, meeting facilitation or public speaking

The M&E plan defines this indicator as the number of members of coordination structures completing more than five days of training in leadership skills, as measured through the CNLS intervention monitor-ing database. As this database was not developed to capture this type of information, progress was assessed by reviewing the various leadership-related trainings that were reported on during the review period. In the review period, all 60 CDLS TAs, members of umbrellas and four CNLS employees participated in leadership training activities.


Strengthen administrative and managerial capacity of institutions

Number of members of coordination structures trained in administration and management

The M&E plan defines this indicator as the number of members of coordination structure trained for more than five days in administration and management during the reporting period. The plan cites the CNLS intervention monitoring database as the data source. As this database wasn’t developed to capture this informa-tion during the review period, a review of administra-tion and management trainings conducted during the review period was conducted with relevant documents.

With the CHAMP project which began in 2005, CNLS had negotiated in their mandate, capacity build-ing of Rwandan organizations of the civil society in areas of administration and management of commu-nity-based programs in the fight against HIV/AIDS. During the review period, 13 civil society organizations, including RRP+ benefited from several training events by CHAMP in this area.

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Assure that necessary resources for operations are available

Number of coordination structures that obtain and spend their annual budgets

The M&E plan defines this indicator as the number of coordination structures out of the sum total of all identified that obtain higher than 80% needed fund-ing for their annual budgets and spend 80% of money obtained within the funding year. The plan does not cite a data source for this indicator, but indicates that CNLS, development partners, umbrellas, and MINE-COFIN were responsible for reporting. As such, no routine reporting systems were put in place to collect this type of information. Progress was assessed by a document review of relevant documents and key infor-mant interviews. As explained above, CNLS and CDLS structures have been funded regularly through govern-ment’s funds and various international funded projects. The umbrellas were also receiving stable funds until the end of 2007 with the World Bank’s MAP project and other projects for specific operational functioning. With 2008 and the end of MAP project, several umbrellas organizations have experienced financial difficulties and have been forced to reduce their staff and their volume of activities.

output5.1.4 indicator

Harmonize the directives and communications across all intervention domains

# of communications sent jointly by central coordinating authority

The M&E plan defines this indicator as the number of formal written directives, statements, and requests issued in 12 month reporting period which were signed by 2 or more implicated coordinating authorities. The plan cites ad-hoc reports as the data source. As such a thorough document review was conducted of relevant documents. The harmonization of directives and com-munications was one of the reasons for the creation and formalization of some steering committees such as PEP-FAR, GLIA, Research, IEC/BCC and joint planning processes implemented by the ONE UN. Most steering committees meet on a regular basis (usually monthly). The results achieved by these bodies are: harmonization of intervention strategies and approaches, same under-standing of policies in the area of the fight against the AIDS and especially the allocation of resources where the needs are more pressing.


Assure that HIV/AIdS strategies within national sector plans are implemented

Number of HIV/AIdS-related objectives in national sector plans that have been achieved.

The M&E plan defines this indicator as the number of HIV/AIDS related objectives across all (sum total) of the sector plans which have been achieved. The plan cites a desk review of sector plans as the data source. This desk review was part of the document review of related documents conducted. In 2005, PRSP was the national strategy for poverty reduction and each sector also had its own sector strategic plan. In all of these documents, HIV was not integrated or was integrated as a health issue (in PRSP) and not as a cross-cutting issue that affects all sectors in their economic and social aspects.

However, certain activities were implemented by sectors through their projects. With the development of ED-PRS (Economic Development and Poverty Reduction Strategy) in 2006 and 2007, CNLS and its partners took advantage of this opportunity to integrate HIV/AIDS as a cross-cutting issue in various sectors. To be able to achieve this, CNLS mobilized a focal point to attend EDPRS Strategic Planning of each sector and to facilitate this work. In 2007 EDPRS was launched and out of the twelve sectors, 11 integrated HIV/AIDS activities in their strategic planning. The same approach used with sectors was applied for the districts in the elaboration of their development plan.

In addition to EDPRS, although a good number of administrative sectors and districts could integrate HIV/AIDS in their strategic planning; this integration remained partial because it was not taken into account during the annual planning to be part of sector mid-term expenditure frameworks. This reflects an often-expressed expectation of sectors that CNLS should fund and oversee the implementation of HIV/AIDS activities integrated in sectors. This attitude of the sectors, which is also found at the level of districts, indicates lack of ownership of HIV/AIDS control activities at these lev-els, despite the work of advocacy that has been carried out.

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develop and disseminate approaches and methods for integrating HIV/AIdS into national sector plans

Number of national sectors/ ministries that have dissemination workshops reviewing methods for integrating HIV/AIdS

The M&E plan defines this indicator as the cumulative number of national sectors which held a workshop to review methods for integrating HIV/AIDS into their national plans. The plan sited CNLS review of sector plans and workshop reports at the data source. The methodology of integrating HIV/AIDS into sectors was developed and disseminated in 2007 during the na-tional planning of Economic Development for poverty Reduction Strategy (EDPRS). Therefore, each sector of EDPRS was informed on the impact of HIV/AIDS on its sector and a checklist of relevant activities to be integrated was also proposed.

In 2008, the launching of the integration of HIV into sectors enabled the elaboration, during a workshop with each sector, of actions for which they are responsible and the way in which these activities are implemented.


Assure that leaders advocate for integrating HIV/AIdS in each sector

Number of advocacy-related activities in multi-sector annual work plans that have been completed.

The M&E plan defines this indicator as the number of advocacy-related activities in multi-sector annual work plans as developed and presented through the HIV/AIDS focal points that have been completed. The plan cites analysis of work plans during annual work plan presentations at the data source. The advocacy was a continuous activity of CNLS and its multilateral part-ners so that sectors can also contribute their response to problems met in the area of HIV/AIDS control.

It is also thanks to this advocacy that the Ministry of Finance and Economic Planning led the working group on the integration of cross-cutting issues in EDPRS to ensure that they are taken into account in sector planning. CNLS is currently in the process of carrying out advocacy for effective integration of HIV/AIDS in sectors’ MTEF, to give the responsibility to sectors to mobilize funds for the implementation of their HIV/

AIDS activities and to ensure their implementation and reporting. This effective integration will be the sign of ownership of HIV/AIDS control activities by economic sectors which is the aim of CNLS for the sectors.


Establish an awards mechanism ceremony for best interventions and agencies in each sector

Number of sectors holding annual award ceremonies in which HIV/AIdS interventions are recognized

The M&E plan defines this indicator as the number of sectors holding annual award ceremonies in which HIV/AIDS interventions are recognized, citing the annual sector review as the primary data source. No sys-tems were put in place in 2005 or 2006 because sector activities, as it has just been mentioned above, were not integrated in their plans. With EDPRS, it is perhaps a mechanism to be reconsidered in the next AIDS strate-gic planning.


Increase HIV/AIdS related regional activities that are jointly executed

Number of regional interventions that are jointly executed

The M&E plan defines this indicator as the number of cross-border activities executed by Rwandans for which there are similar, coordinated activities executed by the country sharing that border and for which ether are meetings to plan and/or exchange experiences/ideas. CNLS reports on regional joint interventions are cited as the data source. Rwanda is engaged in the fight against HIV/AIDS at the regional level with GLIA since 2005 and 2007 with the East African Community.

With GLIA, HIV/AIDS activities are based in tran-sit sites along the borders: KANYARU Border Post (District of HUYE), RUSUMO Border post (KIREHE District) and of RIBAVU Border (RUBAVU District), and other activities are carried out in refugee camps in GICUMBI and KARONGI Districts and among the neighboring population. With EAC, Rwanda benefits from capacity building for the integration of HIV/AIDS into development programs and participates in the harmonization of respective actions and policies on the area.

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Harmonize regional and cross-border related HIV/AIdS policies and frameworks/documents

Percentage of Rwandan national and sector-specific HIV/AIdS plans and frameworks that are consistent with regional plans and framework

The M&E plan defines this indicator as the percent-age of national and sector-specific HIV plans and frameworks that are consistent with regional plans and frameworks, citing GLIA reports as the data source. This objective is registered in the GLIA Project of mem-ber States but initially, each country must harmonize its care protocols to internal policies before this can be achieved at the regional level. In spite of several regional meetings, this process of harmonization is progressing slower than planned and this result has not yet been achieved. However, targeted services towards long distance truck drivers are being offered along the main road transport corridors of the region and this is setting the stage for this future harmonization.


Assure that jointly developed cross-border activity plans are executed

Number of joint cross-border work plans executed

The M&E plan defines this indicator as the number of joint cross-border work plans executed, with GLIA re-ports cited as the data source. The same remark applies to this Output. Each country must first put in place its activities at the borders before they are harmonized with neighboring countries.


Make available necessary resources (funds) for the execution of regional HIV/AIdS interventions

Number of regional HIV/AIdS interventions/initiatives that obtain and spend their annual budgets

The M&E plan defines this indicator as the number of regional HIV interventions/initiatives out of the sum total of all identified that obtain more than 80% needed funding for their annual budgets and spend 80% of money obtained within the funding year. The CNLS reports for GLIA are the cited data source. The GLIA Project is funded for 4 years, but faces difficulties

in the rate of disbursement and the availability and the predictability of funds budgeted for. Member States try to diversify their funding sources of this regional project by submitting a proposal to CCM/GF.


Assure that intervention agencies benefit from national planning and monitoring as much as the coordination agencies

Number of MSC stories that address intervention agencies perception of usefulness/benefits of contributing to national planning, M&E

The M&E plan defines this indicator as the number of most significant change stories that are submitted to CNLS and meet review criteria. As mentioned above for similar indicators, no formal system for the collec-tion or analysis of most-significant change stories was established during the review period. As such, a docu-ment review of relevant documents and key informant interviews were conducted to assess progress.

In national planning, development partners, mem-bers of civil society, economic sectors and CDLS are involved. They are members of various coordination committees in which national priorities in the area of HIV/AIDS control are defined. At the beginning of the planning period, consultations with partners, CNLS, TRAC PLUS, MOH, NRL, CAMERWA, Umbrellas and Districts are organized. But the true benefit that could be obtained by all these institutions and organiza-tions would be the participation and implementation of programs whose planning was indicated by evidence.

That is not often the case, which indicates the lack of the capacity of the districts and stakeholders to trans-late evidence into action and the lack of access (or the inexistence) to certain data at the district level. There is certainly a gap in the capacity of districts which do not have access or do not use research and monitoring results (PLACE, sentinel sites, HIS) to identify their priorities. Apart from these weaknesses, it must be noted that it is difficult to synchronize planning periods of all partners, which is particularly important in assur-ing that during their planning they take into account priorities identified by the district.

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output 5.4.1: indicator:

Simplify and harmonize planning and monitoring tools

Indicator variables collected by national coordination structures and large bi/multi-lateral projects

The M&E plan defines this indicator as the number of indicator values submitted by intervention agencies that are comparable, defined as all agencies understanding and applying the same operational definition in their reporting. The annual data quality studies conducted by TRAC Plus and CNLS are cited as the data source. At the beginning of the NSP period, various formats of planning and reporting tools were used by partners, often for the purpose of their financial donors.

However, these various tools did not meet the national requirements for information needed for better coor-dination of the response to HIV/AIDS. In 2006, the CNLS defined harmonized planning and reporting tools. Partners were trained on the use of these tools, and thanks to constant feedback on the difficulty in their utilization, CNLS was able to gradually improve them.


The level of detail needed for national planning and work plan monitoring is appropriate for national level reporting

number of activities identified in work plans submitted to CNLS

The M&E plan defines this indicator as the number of people completing training for more than five days in data interpretation and use, with Rwandan indicators and data during the reporting period. The plan cites the CNSL intervention monitoring database as the data source. As the database wasn’t developed to collect this type of information, a document review of relevant documents was conducted to assess progress.

The level of details of data collected with planning and reporting formats is the necessary minimum to guide coordination both at the national and decentralized level. This level of details permits the analysis of the geographical equity in distribution of services, benefi-ciary groups, the funding by interventions, by district and by financial donors. Partners often find difficult the use of this list in which, despite details in the descrip-tion of these activities, they cannot find one that cor-responds to their actual intervention.


Strengthen capacity to facilitate planning and monitoring workshops and meetings

Number of coordination structure personnel trained in facilitating planning workshops/meetings, and in reporting

The M&E plan defines this indicator as the number of organizations regularly participating in TWG to de-velop/modify/validate national M&E products. M&E TWG meeting minutes are cited as the data source. Trained CDLS and umbrellas have the mandate to train their members on the coordination mechanism, on the utilization of the tools and to facilitate coordination meetings at their level. However, CDLS and Umbrellas do not play their role adequately at this level, and this training of local organizations is severely lacking. There is definitely a gap in the capacity of CDLS and umbrel-las to provide technical assistance to their local organi-zations for better coordination.


Assure that the national HIV/AIdS strategic framework and M&E plan are used by all agencies for activity planning & monitoring

Percentage of activities identified in work plans submitted to CNLS that correctly identify the Axe, IR and sub-IR as well as the indicator(s) to which they contribute

The M&E plan defines this indicator as the number of M&E products that stakeholders have obtained/ac-cessed and, if they use them, they find them usable. An email or phone survey conducted by CNLS is the data source. No structures were put in place to collect data on this indicator and an email/phone survey was out of the scope of this review. As such, relevant document review and key informant interviews were conducted. The 2005-2009 NSP was a document very open to any kind of interventions. Most interventions could be considered as aligned with NSP objectives because these objectives were general and non-specific. The NSP document did not define all processes, approaches or strategies for the attainment of the objectives, which left room, for the majority of interventions, to innovation and creativity of actors. It is this weakness of the 2005-2009 NSP, in terms of policies and specific national strategies, which led to the fact that the delivery of services was not uniform in terms of approach, contents

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(package of priority services) and even in terms of qual-ity. However, national institutions involved in the fight against the HIV/AIDS progressively improved their performance and coordination and started to speak about harmonization and alignment of interventions to specific policies and strategies that are developed. It remains that the definition of strategies, of service pack-ages and of quality standards is a challenge for the next 2009-2012 NSP.


V.5 Jointly evaluate the multi-sector response to HIV/AIdS

Mid-term review of HIV/AIdS national response (2007) and end-of period evaluation (2009/10) are jointly executed with representation from all stakeholders.

The mid-term review of the 2005-2009 NSP did not take place in 2007 as planned in the indicator because the plan had been launched only in December 2005. In 2008 it was decided to review it because it had become obsolete, compared to the evolution of the HIV/AIDS sector. It had to integrate new objectives in EDPRS, the roadmap for universal access and various strategic plan-ning activities of partner institutions (TRAC PLUS, MOH). The planned mid-term review therefore did not take place, it was rather decided to carry out the final review of the NSP early to lead to the elaboration of a new plan. The process of the review of the current NSP was communicated to all partners. Thematic working groups were formed with the participation of devel-opment partners. The preliminary report was shared within the M&E TWG and then with the group of decision makers.


Harmonize and operationalize national indicators, M&E and planning tools

Indicator values submitted by intervention agencies are comparable.

Same M&E and planning format are used at district level by interveners


Strengthen capacity at all levels to evaluate the national response

Number of people trained in data use/interpretation using indicators & data


Jointly develop and validate information products from national evaluations

Number of organizations regularly participating in TWG to develop/modify/validate national M&E products


Assure that national M&E products are available and useable

Number of M&E products that stakeholders have obtained/accessed.


Coordinate research and training

Existence and use of national long-term or annual HIV/AIdS-related research plans

In 2007, an M&E system assessment and review was conducted in order to assess strengths and weaknesses in the current M&E system and propose capacity-building recommendations. All of the above outputs were covered in the M&E system review presented below in Section 4.2.

4.1.3 – Key Achievements and Major Challenges and GapsSingle Planning, and monitoring and evaluation mecha-nism: The major result in planning and coordination of the 2005-2009 NSP is the creation and the for-malization of a single planning mechanism for all the stakeholders with planning and reporting tools. The development of harmonized planning and reporting tools in addition to the implementation of the CDLS and various technical working groups help to ensure that all development partners were working within the same framework.

HIV integration into other sectors: Through the EDPRS process that was implemented starting 2007 HIV is successfully being integrated into most sector plans as a cross-cutting activity. Though additional work needs to be conducted to ensure harmonized planning and reporting of HIV cross-cutting areas between the relevant sectors, district authorities and CNLS, most sector long-term strategies have incorporated HIV as a cross-cutting issue.

District-level capacity building: The CDLS have limited capacity in planning, coordination and monitoring and evaluation. During the review period the majority of efforts were concentrated on the establishment of the district level committees and the implementation of

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the planning and M&E system. As this mechanism is now in place it will be important to focus on capacity-building interventions moving forward.

4.1.4 – Key Recommendations• Continue capacity-building efforts with CDLS

and umbrellas to ensure that they are able to adequately fulfill their job responsibilities.

• Better define the planning and reporting mechanisms for HIV cross-cutting issues in non-health sectors.

• Work to strengthen coordination mechanisms between TRAC Plus and CNLS.

4.2 – MonitoRinG AnD evALUAtion

4.2.1 – Assessment of M&E system In 2007 CNLS organized a participatory assessment of the national M&E system with the support of the MOH, World Bank/GAMET, the Global Funds, UN-AIDS and MEASURE Evaluation. The analysis follows the internationally agreed 12 components Framework. Table 4.2.1 on page 89 provides an overview of the M&E situation in Rwanda for HIV in 2005 and 2008.Data for 2005 are from CNLS staff. The assessment also covers the M&E-related outcomes and output from Section 4.1.2 above.

4.2.2 – Key Achievements and Major Challenges and Gaps In general, the monitoring and evaluation system at the national level is reasonably strong, but the M&E sys-tems within the district and community levels are fairly weak. A lot of valuable information is collected at the periphery, and good guidelines and tools are developed, but both information and tools often fail to reach the end user through improper or lack of dissemination.

Other major challenges include the following:• Lack of human capacity in both quantity and

skills, in particular at the decentralized level and within sectors.

• There is need to improve feedback mechanism related to routine HIV program monitoring at the national and sub-national levels.

• Data analysis and use (including use of CNLSnet data) for decision making is still inadequate.

• Some of the partners at the national level are not included into the current M&E system (need to extend CNLSnet to partners at the national level).

• An M&E system inclusive of all EDPRS sectors is not yet in place.

• Clear targets, baseline data, definitions and frequency of data collection are missing for some of the national indicators.

4.2.3 – Key Recommendations • Develop and implement a practical, skills-based,

human capacity development plan that includes M&E at national and decentralized levels.

• Ensure that HIV interventions under EDPRS are monitored by sector-specific M&E frameworks but also captured by the National HIV M&E plan.

• Provide technical assistance to develop coherent links between the M&E subsystems existing in the country (in particular with reference to EDPRS sectors).

• Revision of the M&E National plan in line with the EDPRS framework (and in parallel with the new NSP 2008-12).

• Improve the functioning of the Planning, Monitoring and Evaluation Technical Working Group (PM&E TWG).

• Include national partners (for activities with a national focus and not taking place in specific districts) into the existing CNLS M&E system and CNLSnet database.

• Strengthen the feedback system related to routine HIV program monitoring (including CNLSnet).

• Enhance the capacity of end data users to more effectively utilise the results from M&E and operational research and to feed back into planning and service delivery.

• Finalize the process of defining baselines, data collection sources, definition, targets and measurement frequencies for the national indicators.

• Adaptation of the current guidelines and operational planning tools (in particular the activity coding) to the new NSP 2009-12.

• Develop guidelines for data auditing and supervision.

4.3 – ReSoURCe MobiLizAtion AnD ALLoCAtion

4.3.1 – National Health Accounts (NHA) and Na-tional AIDS Spending Assessment (NASA)To track HIV-related expenditure for 2006, Rwanda

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used two different frameworks, the National AIDS Spending Assessment (NASA) and the National Health Accounts (NHA). Data from an existing household survey on out-of-pocket spending by PLWHA commis-sioned by CNLS were also included (refer to 2007/08 UNGASS Report for more detail). Data for 2005 were based on donors’ declarations about expenditure and reported in the UNGASS Report 2006. Data for 2007 came from declarations of expenditures by key donors in the country and data for 2008 are mainly budgetary projections by the same key donors.

It is important to note that data for 2005 (and for pre-vious years) and 2007 refer to declared expenditure by donors while data for 2006 reflect actual expenditure by providers. Therefore data for 2006 are a more accurate figure of real expenditure for HIV in the country. Data for 2005, 2007 and even more data for 2008 (budget projections) may be overestimated. Given the diverse nature of these data, any trend analysis should be taken with precautions.

Financing Sources: The financing of the HIV/AIDS response in Rwanda comes from many sources: through government ministries and other public institutions, the private sector which includes corporations, out-of-pocket household expenditures, and international partners, such as UN agencies, the ADB, the World Bank’s Multi-sectoral AIDS Project (MAP), the Global Fund, the United States Government (USG) through PEPFAR, and other bilateral donors.

Total HIV spending in 2006 is USD 87.6 million. When comparing with previous years, an increasing trend in expenditures is noted. Declared expenditures in 2005 were $81.4 million, $44.85 million in 2004, and $ 9.6 million in 2003. Since data for 2005 and previous years refer to declared expenditure by donors while data for 2006 reflect actual expenditures by providers, these figures may in fact underestimate the increase that hap-pened in 2006. The total amount of spending for 2006 represents 3.3% of the GDP in Rwanda.

In general 92% of the HIV/AIDS spending is incurred by donors. However, Government contributions increased by about $1.4 million since 2005 (UNGASS Report, 2006). Out of pocket spending by PLHIV on health care is 1.2 times more than the general popula-tion. This represents a decrease from 2.99 times more in 2002 (NHA records). Expenditure from private sources, including out-of pocket spending by PLWHA,

represents only 2.7% of the total. Total amounts de-clared by key HIV donors in 2007 and 2008 were of $146,203,621 and $203,597,944 respectively. These amounts represent substantial increases from the values in 2006. However, as mentioned above, there are considerable differences between money provided to the country as declared by donors and funds effectively spent in the country by service providers.

Financing by HIV Program Intervention — 2005, 2006, 2007 and 2008: Table 4.3.1 on page 91 breaks down the total spending by category from the period 2005 through 2008. HIV prevention program expenditure: Government funds are spent mainly on programs covering blood safety, community mobilization, school HIV prevention programs, and programs for vulnerable populations. Donors’ funds cover VCT, mass media, management of STIs and PMTCT. Increases in preven-tion funds are much lower than increases in treatment and care over the years.

Care and treatment programs: From 2005 to 2006, although the number of patients increased steadily, a significant reduction in the prices for ARVs and for some tests compensated the increase in quantities and balanced the overall increased costs for OIs and other tests. In 2007 and 2008 it seems that funds on treat-ment more than doubled the investments in HIV pre-vention. HIV health-related expenditure as a percentage of the total spending on HIV was 84.3% in 2006.

Overall, HIV/AIDS health care spending accounts for 24% of all health care spending in 2006. This repre-sents an increase from 15% in 2005, according to NHA records. No such estimates are yet available for 2007 and 2008.

GlobalFund

MAP

ADB

UNAgencies

USG‐PEPFAR

PublicSources

OtherPrivate

Out‐of‐pocket

CorporaDons

Otherdonors

GlobalFund

14.8%

MAP

13.2%

ADB

1.0%

UNAgencies

2.5%USG‐PEPFAR

32.9%

PublicSources

5.0%

OtherPrivate

0.4%

Out‐of‐pocket

2.2%

MorporaNons

0.1%

Otherdonors

27.8%

Figure4.3.1:ExpenditureperFinancingSource,2006

figure 4.3.1: expenditure per financing source, 2006

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Impact mitigation — Funding for orphans and other vulnerable children: The government amounts for 2005 and 2006 include an estimated proportion (20%) of the Genocide Survivals Fund (FARG) to support education for OVC in the country. This proportion relates to the percentage of OVC infected or affected by HIV. Much of this amount goes for OVC education in terms of school fees. Overall, increases in funds for the impact mitigation Axis (also including funding for income-generating activities for PLHIV) seem much lower than for the other areas of the HIV response.

HIV- and AIDS-Related Research (excluding operations research): 2005 data take into account the spending for two big studies, the RDHS 2005 and the PLACE study. Funds spent or research diminished in 2006 and data are not yet available for 2007 and 2008.

4.3.2 – Key limitations and recommendationsTrends analysis in expenditure over the years presents

major limitations. As explained above, apart from 2006, where data refer to funds actually spent in the country by service providers, the figures for the other years may be strongly inflated. Figures including budgets may be even more inflated than declared expenditures by key donors. Also, due to lack of disaggregated data, for some of the key donors broad estimates were carried out to share expenditure over the NSP axis for 2008 and 2009. The real allocation of resources to the axis may be different than the one suggested. A National AIDS Spending assessment for the years 2007 and 2008 will be carried out in 2009 and it will allow a better analysis of trends and spending by categories.

Data referring to districts budgets may be incomplete. Data come from the online updated CNLSnet database in late 2008, and since it was the first time for districts to use the updated version of the database there may be errors or omissions — a quality check on district data submitted electronically will be carried out in 2009.

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tAbLeS

tAbLe 3.1.1: AXiS i iMpACt, oUtCoMeS, AnD oUtpUtS in tHe nSp Reinforce measures for preventing Hiv/AiDS transmission

Change high risk sexual behavior

Promote EABC through IEC for behavior change

Increase access to and use of condoms

Educate youth on sexual responsibility

Increase the number of people in the population that know their HIV/serological status

Increase the proportion of the population that knows the causes, symptoms and consequences of STI, OI and TB

Change behavior of health personnel to reduce transmission of HIV and AIdS, STI, OI and TB

Adopt universal precautions in health-care related establishments

Adopt provider-initiated diagnosis of STIs, OIs and TB

Adopt blood safety measures

Reduce the transmission of HIV through medical prophylaxis

Motivate more pregnant women and their partners to use Prevention of mother to child transmission (PMTCT) services

Increase access to high quality PMTCT services

Assure Post Exposure Prophylaxis (PEP) for health care personnel

Assure PEP for rape victims

Create a cultural environment more favorable to preventing HIV & STI transmission

Promote (the retention of ) Rwandan cultural practices that contribute to preventing HIV and STI transmission

Promote abandoning Rwandan cultural practices that contribute to the transmission of HIV and other STIs

– 76 –

tAbLe 3.1.2: pRevALenCe of Hiv in DiffeRent popULAtion GRoUpS ACCoRDinG to DHS AnD AnC SURveiLLAnCe

General population according to different demographic categories: % Hiv positive [95% confidence interval]

RDHS 2005 (4) eDpRS target for 2012 (15)

Rural residents Women 2.6 [2.1-3.1] –

Men 1.6 [1.1-2.1] –

Total 2.2 [1.8-2.6] –

Urban residents Women 8.6 [6.9-10.3] –

Men 5.8 [4.2-7.3] –

Total 7.3 [6.0-8.6] –

No education Women 3.3 [2.3-4.3] –

Men 3.0 [1.8-4.3] –

Total 3.2 [2.4-4.0] –

In union (married or cohabiting)

Women 2.8 [2.2-3.4] –

Men 3.5 [2.7-4.3] –

Total 3.1 [2.6-3.6] –

Widows Women only 15.9 [11.1-20.6]

15-24 years Women 1.5 [1.0-2.0] –

Men 0.4 [0.1-0.7] –

Total 1.0 [0.7-1.3] 0.5

15-49 years Women 3.6 [3.1-4.1] –

Men 2.3 [1.8-2.8] –

Total 3.0 [2.6-3.5] –

women attending antenatal clinics according to different demographic categories: % Hiv positive [95% confidence interval]

AnC 2005 (35) AnC 2007 (32) p (one-sided)

Rural sites 2.2 [1.9-3.6] 2.3 [2.0-2.6] 0.362

Urban sites (Kigali) 12.8 [10.8-15.1] 11.7 [9.7-13.7] 0.251

Urban sites (other than Kigali) 5.0 [4.5-5.6] 5.6 [5.0-6.2] 0.088

No education 3.6 [3.0-4.2] 3.8 [3.2-4.5] 0.35

In union (married or cohabiting) 3.9 [3.5-4.2] 4.0 [3.7-4.3] 0.352

Widows – 9.7 [2.9-16.7] –

First pregnancy 2.9 [2.3-3.5] 3.6 [3.0-4.2] 0.059

15-24 years 3.5 [3.0-4.0] 3.7 [3.2-4.3] 0.311

15-49 years (all study subjects) 4.1 [3.8-4.5] 4.3 [3.9-4.6] 0.25

– 77 –

tAbLe 3.1.3: SeLeCteD DAtA on Hiv pRevALenCe AMonG vCt CLientSHiv prevalence among vCt clients according to different sources and population groups (%)

2006 2007 Jan-June 2008

tRAC pLUS and MoH Annual reports (25; 26; 33; 34)

General population Women 8.3 – –

Men 6.6 – –

Total 7.6 4.7 3.8

Age group <18 5.1 2.7** –

18-25 4.5 3.2** –

>25 10.8 6.6** –

Residence location Rural sites – 2.2 –

Urban (Kigali) 13.6 12.8 –

Other Urban – 5.0 –

pSi (30)

Prisoners tested in mobile VCT 10.2 5.2 4.1

Female sex workers tested in mobile VCT – 19.2 16.4

Truckers tested in mobile VCT – 17.4 6.9

various sources (30)

Prisoners testing since the start of 2008* – - 6.7

* The data on testing in prisons were compiled by the data triangulation team in August 2008. For the purposes of this table, HIV prevalence has been calculated only for prisons where VCT has been introduced since the beginning of 2008 (8 prisons).** Figures for January-November 2007 only.

– 78 –

tAbLe 3.1.4: RepoRteD SeXUAL beHAvioR inDiCAtoRS foR DiffeRent DeMoGRApHiC CAteGoRieS

indicator : % of respondents reporting each behavior [95% confidence interval]

Source

DHS 2005 (4) bSS 2006 (29) eDpRS target for 2012 (15)

Sex with more than one partner in the past 12 months

Women 2.3 [0.0-4.7] 0.8 [0.4-1.2] –

Men 4.9 [0.0-10.4] 1.9 [1.3-2.5] –

Total 2.8 [0.6-5.1] 1.3 [1.0-1.6] –

Condom use during last high risk sex (among those reporting high risk sex)

Women 27.6 [17.7-37.3] – –

Men 37.3 [25.0-49.6] – –

Total 31.7 [23.9-39.4] – –

Systematic condom use during the past 12 months

Women – 1.3 [0.0-3.8] –

Men – 1.1 [0.0-3.2] –

Total – 1.2 [0.0-2.8] –


Women 1.0 [0.5-1.5] – –

Men 4.4 [2.2-6.6] – –

Total 1.7 [1.1-2.4] – –


Women 26.4 [20.2-32.6] – 35

Men 39.5 [31.9-46.9] – 50

Total 32.3 [27.5-37.1] – –

Systematic condom use during the past 12 months

Women – – –

Men – – –

Total – – –


Women 0.6 [0.4-0.8] – –

Men 5.1 [4.2-6.0] – –


Women 19.7 [16.2-23.4] – –

Men 40.9 [35.5-46.1] – –

– 79 –

tAbLe 3.1.6: nUMbeR of peopLe tRAineD to DeLiveR ieC/bCC people trained 2006 2007 Jan-June 2008

Minimum total people trained on Abstinence and Be Faithful only (% in relation to total trained)

13,513 (82%) 20,228 (89%) >271 (data not yet available)

Total people trained on IEC/BCC HIV prevention 16,396 18,989 >6,715

tAbLe 3.1.7: eStiMAteD nUMbeRS of peopLe ReACHeD bY DiffeRent ieC/bCC MetHoDS people reached 2006 2007 Jan-June 2008

Total people reached by outreach IEC/BCC methods 912,288 1,947,687 >1,534,580

CNLS telephone hotline 27,515 58,174 21,173

CNLS documentation centre 5,831 6,942 4,249

Total reached by different methods >945,564 >2,012,803 >1,560,002

tAbLe 3.1.5: bASeLine DAtA on RepoRteD SeXUAL beHAvioR inDiCAtoRS foR SeLeCteD pRioRitY tARGet GRoUpS

indicator : % of respondents reporting each behavior Source

RDHS 2005 (4) bSS 2006 (29)

people with no education (aged 15-49), reporting


Women 0.4 -

Men 3.7 -

Total 1.1 -


Women 14.0 -

Men 30.5 -

Total 18.6 -

people in union (couples), reporting


Women 0.2 -

Men 4.7 -

Total 2.8 -


Women 9.8 -

Men 38.6 -

Total 30.4 -

Sex workers (women) having had at least one client in the past week

Used a condom during last sex with a client _ 86.6

Report having used a condom “every time” they had sex with a client in the past week

_ 45.6

truck drivers (men)

Reporting having paid for sex in the past 12 months _ 18.5

Of those reporting having paid for sex

Those reporting using a condom last time they had sex with a sex worker

_ 82.1

Those reporting using a condom every time they had sex with a sex worker

_ 59.5

– 80 –

tAbLe 3.1.8: KnowLeDGe of tRAnSMiSSion AnD pRevention of Hiv AMonG DiffeRent popULAtion CAteGoRieS

indicator (values in %) Source

RDHS 2005 (4) bSS 2006 (29)

Complete knowledge on HIV and AIdS (composite indicator)

Women 45.3 12.9

Men 49.0 16.8

Knowledge of condoms as means of preventing HIV

Women 76.9 54.2

Men 86.9 66.4

Total 79.9 60.1


Women 50.9 –

Men 53.6 –


Women 79.5 –

Men 88.4 –

Total 82.1 –


Women 53.6 –

Men 57.5 –


Women 80.0 –

Men 89.7 –

Complete knowledge on HIV and AIdS (composite indicator) – 36.2

Knowledge of condoms as means of preventing HIV – 83.0

Complete knowledge on HIV and AIdS (composite indicator) – 39.1

Knowledge of condoms as means of preventing HIV – 73.2

– 81 –

tAbLe 3.1.9: AvAiLAbLe DAtA on MALe ConDoM DiStRibUtion bY pRoGRAMMenumber of male condoms distributed according to different distribution channels

2006 2007 Jan-June 2008

Global fund annual reports

Sold (social marketing) 0 0 1,000,000

world bank MAp annual reports

Free distribution: community and private sector

Workplaces 51,840 No data No data

General population 915,600 No data No data

ATRACO No data 750,000 229,166

Free distribution: public sector Civil servants 24,294 No data 40,584

Military and police 1,690,861 3,454,505 No data

Total condoms distributed under MAP* 2,531,683 4,204,505 810,992

USG annual reports

No data available for yearly totals. However, total number of condoms shipped by USG from 2004-2007 is given as 39,756,000

CnLS annual reports on AiDS response

Sold (social marketing) 10,000,000 6,789,544 No data

Sold according to district reports No data 2,068,367*** No data

Free distribution: military and police 7,994,038 No data No data

Free distribution: students 254,520 No data No data

Free distribution: public sector workplaces 44,328 No data No data

Free distribution: other public sector channels 280,000 No data No data

Free distribution: according to district reports 663,153*** 2,001,811*** No data

Free distribution: VCT clinics No data 19,759 No data

Total condoms distributed and sold as stated in report 26,543,501*, ** No data No data

estimate of total male condoms distributed according to project reports

26,543,501 >10,994,049 >2,080,742

Estimate of number sold 10,000,000 6,789,544 1,000,000

Estimate of number sold as a percentage of total 38% 62% 48%

* Note that totals are not all consistent with subtotals. The data is presented here as it appears in the source report. National totals at the bottom of this table are based solely on figures that are underlined, in order to avoid double-counting. Where inconsistencies cannot be resolved, the higher figure has been used. ** This total includes 12,468,937 condoms via the Global Fund; however the GF reports do not mention any condoms distributed and condom distribution does not appear in the proposal for the GF Round 3 HIV project that was being implemented in 2006. The total also includes 3,687,966 distributed through the MAP project, a figure which is much higher than the one that appears in MAP reports (see above).*** district report figures are included for illustration only and have not been used in calculation of totals. It is likely that they are already included in the national totals provided.

– 82 –

tAbLe 3.1.11: DAtA on pRoviSion of Life SKiLLS eDUCAtion in SCHooLSindicators on life skills education 2006 2007 Jan-June 2008

Teachers trained in life skills education 6,566 3,417 No data

Total people reached by life skills training >192,881 >79,239 >544,700

tAbLe 3.1.12: AttitUDeS of pARentS towARDS eDUCAtinG CHiLDRen on ConDoM USe AS A MeAnS of pReventinG AiDS


RDHS 2005 (4)

Adults agreeing that children age 12-14 should be taught about condom use to prevent AIdS

Women 80.2

Men 82.4

tAbLe 3.1.13: peRCentAGe of YoUnG neveR MARRieD peopLe wHo HAve neveR HAD inteRCoURSe


RDHS 2005 (4) bSS 2006 (29) UniCef 2007 (1)

Percentage of never married young people aged 15-19 who have never had sexual intercourse (UNICEF are for 15-18 only)

Women 90.6 86.9 –

Men 77.5 76.3 –

Total 86.6 81.8 81.7

Percentage of never married young people aged 15-24 who have never had sexual intercourse

Women 86.2 – –

Men 67.0 – –

Total 79.8 – 54.2-81.7

tAbLe 3.1.10: MALe ConDoM ConSUMption 2006-2008 ACCoRDinG to tHe ConDoM pRoGRAMMinG RApiD ASSeSSMent

Condom programming situational analysis report, 2008 (5)

2006 2007 2008*

Sold (social marketing) 9,979,100 7,508,400 7,552,900

distributed through public sector 833,900 1,649,300 3,453,500

Total male condoms distributed 10,813,000 9,157,700 11,006,400

Number sold as a percentage of total 92% 82% 69%

* Figures for 2008 are based on sales to date and projections to the end of the year, at the time of writing of the situational analysis.

– 83 –

tAbLe 3.1.14: DAtA on peopLe ReCeivinG Hiv teStinGvarious indicators on Hiv testing 2005 2006 2007 Jan-June 2008

DHS survey results

target Result target Result target Result

Number of people receiving pre-test counseling

– – – – 832,466 – 427,687

Number of people receiving counselling who received a test (%)

– 376,442 472,194 500,000 827,979 (99.5%)

– 425,212 (99.4%)

Percentage among those receiving VCT who are women

– – 53.6% – 53.2% – 53.4%

Percentage among those receiving VCT aged over 25

– – 47.2% – 47.5% – 45.9%

Percentage of those tested receiving results

89.3% – 96.7% – 96.6% – 94.0%

Number tested in mobile VCT – – 25,242 (CNLS)

– 22,814 – No data

Percentage among those receiving mobile VCT who are women

– – No data – 48.0% – No data

Percentage among those receiving mobile VCT who are over 25

– – No data – 47.8% – No data

tAbLe 3.1.15: DAtA on pRACtiCe AnD KnowLeDGe ReLAteD to StiSindicator (values in %) Source

RDHS 2005 (4)

bSS 2006 (29)

UniCef 2007 (1)

Young people aged 15-19 having heard of STIs (UNICEF data are for 15-18 only)

Women - 76.0 -

Men - 80.7 -

Total - 78.3 89.8

Young people aged 15-24 having heard of STIs Women - - -

Men - - -

Total - - 89.8-93.8

Sexually active young people aged 15-19 knowing at least one STI symptom

Women - 36.6 -

Men - 46.7 -

Sexually active young people aged 15-24 knowing at least one STI symptom

Women - - -

Men - - -

Sexually active young people aged 15-19 reporting having had at least one STI symptom in the past year

Women 0.6 7.4 -

Men 0.7 3.2 -

Sexually active young people aged 15-24 reporting having had at least one STI symptom in the past year

Women 0.7 - -

Men 0.3 - -

Sexually active people aged 15-49 presenting with STI symptoms in the past year who sought treatment from a health professional

Women 12.0 - -

Men 14.0 - -

tAbLe 3.1.16: Hiv teStinG RAte foR newLY DiAGnoSeD tb CASeSindicator (values in %) 2006 (25) 2007 (26) 2008 (43)

Percentage of TB cases tested for HIV 75.9% 89.0% 93.2%

– 84 –

tAbLe 3.1.17: DAtA on pMtCt pRoGRAMindicators on pMtCt program 2006 2007 Jan-Aug 2008

Number of active PMTCT sites 234 285 330

Pregnant women attending ANC 230,623 223,028 171,134

Pregnant women tested through PMTCT 216,326 212,501 165,966

Percentage of partners testing 52.4% 63% 75.4%

Women testing positive and joining PMTCT program 9,583 8,059 5,528

Women receiving ARV prophylaxis (% of those on program) 6,611 (69%) 6,183 (96%) 3,694

Infants treated with NVP 4,274 5,951 4,687

tAbLe 3.1.18: DAtA on AttitUDeS towARD peopLe LivinG witH HivAccepting attitudes towards people living with Hiv (% on four key acceptance indicators)

DHS 2005 UniCef 2007

Young people 15-19 Women 39.1 –

Men 42.2 –

Total 40.0 41.9

General population 15-49 Women 46.1 –

Men 51.0 –

Total 47.5 –

tAbLe 3.3.1: AXiS 2 iMpACt, oUtCoMeS, AnD oUtpUtS in tHe nSpnational response to Hiv/AiDS adapted to Rwanda’s conditions and surveillance research results

Increase the usefulness of surveillance results with respect to the national response to HIV/AIdS

Improve national systems for case notification of morbidity and mortality related to AIdS

Establish a sustainable behavioral surveillance system

Improve the HIV sero-surveillance by including other HIV/AIdS related diseases

Improve the pharmacological sensitivity surveillance to improve AIdS treatment

Improve the statistical and analytic competencies of surveillance technicians

Increase the usefulness of research results, studies and evaluations

Improve the methodological competencies of researchers

Improve the statistical and analytical competencies of researchers

Involve people to be studied in the identification, design and execution of research

Improve the functioning of the HIV HIV and AIdS Research Committee

Improve ability of stakeholders to interpret and use surveillance and research results

Promote and facilitate the routine availability of surveillance and research results

Improve the analytical capacity of all levels of beneficiaries and decision makers

Strengthen the capacity of technicians and stakeholders to present results in various more usable formats

– 85 –

tAbLe 3.3.2 HeALtH CenteRS (HC) tHAt notifieD AiDS-ReLAteD CASeS AnD DeAtHS tHRoUGH tHe SiS

indicator (values in %) 2005 (n=336) 2006 (n=377) 2007 (n=405)

Percentage of Health Centers reporting AIdS mortality through SIS 90.8% 84.6% 97.5%

tAbLe 3.3.3: nUMbeR AnD (peRCentAGe) of AiDS-ReLAteD DeAtHS RepoRteD tHRoUGH tHe SiS SYSteM

indicator (values in %) 2005 2006 2007

Number of cases of AIdS-related deaths notified through SIS 752 (6.2%) 875 (9.6%) 633 (8.4%)

Estimated number of AIdS deaths 12,153 9,152 7,527

Numerator: SIS, MOH; denominator: Rwanda 2008 HIV Epidemic Update

tAbLe 3.5.1 AXiS 3 iMpACt, oUtCoMeS, AnD oUtpUtS in tHe nSpimprove Hiv/AiDS treatment, care and support for persons infected and affected by Hiv and AiDS

Increase access to high quality care and treatment at health facilities

Assure equitable coverage of ART services with emphasis on pediatric care

Improve treatment of OIs according to national norms and procedures

Reduce the real cost of accessing HIV/AIdS related care and treatment

Promote the approach “Provider initiated diagnosis” (PId)

Improve collaboration and service referrals between health care providers and community agents

Improve therapeutic nutrition support for people on ART

Integrate care and treatment of OIs among other illnesses supported through community health insurance (CBHI)

Strengthen health care providers’ capacity to deliver highest quality of care

Increase access to high quality community based care and treatment

Assure equitable coverage of community based care and treatment services

Improve the community-based care and treatment of PLWHA

Strengthen the technical capacity of people and organizations providing care and support

Integrate home based care and treatment for PLWHA within community based health services

develop and standardize outpatient and mobile treatment services

Improve the nutritional status of people infected and affected by HIV/AIdS

Assure that HIV/AIdS related care and treatment is sustainable

Improve decentralized HIV and AIdS related procurement, management and distribution systems

Increase Rwandan human resources needed for HIV/AIdS related care and treatment

Establish a system to supply communities with required materials

Execute a national plan to assure that the expanded global care and treatment is sustainable

tAbLe 3.5.2: pRoGReSS on # of pAtientS on ARt AnD peRCentAGe of tHoSe LoSt to foLLow Up At tRAC pLUS-SUppoRteD Hiv SiteS.

provinces 2005 2006 2007 Jan-July, 2008

total on ARt Lost to f/u total on ARt Lost to f/u total on ARt Lost to f/u

Kigali city

No data

12,874 1,005 (9%) 16,477 1,440 (10%) 18,757 2,044 (11%)

Eastern 5,559 163 (3%) 7,765 318 (4%) 9,646 355 (3%)

Western 6,359 139 (2%) 6,013 325 (3%) 12,393 450 (3%)

Northern 4,204 312 (7%) 7,878 977 (15%) 7,429 1,144 (14%)

Southern 5,140 135 (3%) 9,936 223 (3%) 9,735 327 (3%)

Total 34,136 1,754 (5%) 48,069 3,283 (7%) 57,960 4,320 (7%)

– 86 –

tAbLe 3.5.3: tHe nUMbeR AnD peRCentAGe of peopLe ReCeivinG ARt oveR tHe totAL of peopLe in neeD, 2005 tHRoUGH JUne 2008.

2005 2006 2007 Jan-June 2008

total total (adults, children)

total (adults, children)

total (adults, children)

Number of patients on treatment

19,058* 34,136 (31,379 adults, 2,757 children)

46,810 (42,810 adults, 4,000 children)

56,703 (51,652 adults, 5,051 children)

Estimated number of patients in need of ART

66,800 66,900 68,700 N/A

Percent coverage 29% 51% 68% N/A

Numerator: TRAC Plus annual reports; denominator: Rwanda 2008 Epidemic Update*No disaggregated data available

tAbLe 3.5.4: tHe peRCentAGe of HeALtH fACiLitieS pRoviDinG ARv SeRviCeS in tHe CoUntRY fRoM 2005

various indicators on ARt treatment coverage 2005 (n=342) 2006 (n=354) 2007 (n=435) 2008* (n=452)

Number of health facilities offering ART 80 133 171 211

Percentage of all health facilities offering ART 23% 38% 39% 47%

tAbLe 3.7.1: AXiS 4 iMpACt, oUtCoMeS, AnD oUtpUtS in tHe nSpMitigate the socio-economic impact of Hiv and AiDS

Improve the socio-economic conditions in Rwanda (and assure vulnerable groups benefit as much as others)

Create employment opportunities in particular for vulnerable groups

Assure access to credit for vulnerable groups

Improve the equity and equality between women and men regarding income generating activities and employment opportunities

Improve access to formal and informal education for target groups with an accent on PLWHIV and OVC

defend and promote human rights Improve the judicial environment for PLWHIV and OVC

Increase the number of employers who have adopted or adapted work place policies that take into account PLWHIV

Protect young girls and women from domestic and sexual violence as well as sexual harassment

Improve operational policies, norms and procedures to assure equitable access to services for PLWHIV and OVCs

Strengthen decision making capacities of associations involved in HIV/AIdS notably through the concept of GIPA (Greater Involvement of People living with HIV/AIdS)

Strengthen managerial capacity of associations involved with HIV/AIdS

Balance of the composition of HIV/AIdS related associations (increase proportion of male, middle class & HIV – members).

Increase involvement of PLWHIV in the planning, execution and review of programs.

– 87 –

tAbLe 3.7.2: fUnDS pRoGReSSion foR tHe iGA MiCRo-pRoJeCtSprogression 2005 2006 2007 Jan-June 2008 total

Number of micro-projects 631 917 816 7 2 469

Funds allocated to beneficiaries (in RWF)

1,010,544,173 1,775,722,034 3,032,262,192 94.749,036 6,258,146,895

Number of beneficiaries 29,760 18,515 33,166 3,655 97,493

Source: CNLS reports 2005-2007

tAbLe 3.7.3: ASSiStAnCe to ovCprogression 2005 2006 2007 Jan-June 2008 total

Beneficiaries 25,364 285,616 134,271 77,432 552,583

Total amount of support to orphans and other vulnerable children (in RWF)

1,125,435,580 1,060,729,799 2,305,133,178 No data 4,682,762,566

Source: CNLS reports 2005-2007

tAbLe 4.1.1: AXiS 5 iMpACt, oUtCoMeS, AnD oUtpUtS in tHe nSpCoordinate the multi-sector response for increased cost-effectiveness

Improve the capacities of national HIV/AIdS coordination structures

Strengthen leadership capacity of personnel

Strengthen administrative and managerial capacity of institutions

Assure that necessary resources for operations are available for coordinating structures

Harmonize the directives and communications across all intervention domains


develop and disseminate approaches and methods for integrating HIV/AIdS into national sector plans

Assure that leaders advocate for integrating HIV/AIdS in each sector

Establish an awards mechanism ceremony for best interventions and agencies in each sector

Increase HIV/AIdS related regional activities that are jointly executed

Harmonize the [regional] HIV/AIdS policies and frameworks/documents

Assure that jointly developed cross-border HIV/AIdS activity plans are executed

Make available necessary resources (funds) for the execution of regional HIV/AIdS interventions


Simplify and harmonize planning and monitoring tools

The level of detail needed for national planning and workplan monitoring is appropriate for national level reporting (in decentralized context)

Strengthen capacity to facilitate planning and monitoring workshops and meetings

Assure that the national HIV/AIdS strategic framework and M&E plan are used by all agencies for activity planning & monitoring

Jointly evaluate the multi-sector response to HIV/AIdS

Harmonize and operationalize national indicators, M&E and planning tools

Strengthen capacity at all levels to evaluate the national response

Jointly develop and validate information products from national evaluations

Assure that national M&E products are availableand useable (to/by information providers and users).

– 88 –

tAbLe 4.1.2: MAin ReSULtS of CHAt eXeRCiSe, ApRiL 2008Chat Category tool//Mechanism Status Responsible partner

1. Strategy development

National Strategic Framework In operation. CNLS/MOH

UN Joint program on HIV/AIdS /ONE UN In operation UN

SWAP – sector wide approach In progress donors/Ministry finance

HIV as cross-cutting in sector programs – EdPRS requirement

In progress Ministry of Finance/all sectors

2. Monitoring and Evaluation (M&E)

1. M&E national plan and roadmap 2. Revised standard list of national indicators

1. In operation 2. In progress

1. CNLS 2. CNLS and NIS

UNGASS Completed CNLS

CHAT In progress/validation CNLS

NASA /NHA To be done for 2007 CNLS and Ministry of Health

Joint mapping of partner needs at the district level

In progress Government

3. Finance Sector Budget support In progress All donors

HACT In progress UN

CAMERWA In operation MOH, CAMERWA

4. Coordination, communication, reporting

Technical working groups and clusters In operation Government and Partners

Joint Action Forum In operation CdLS/district Mayor

CNLSnet In operation CNLS and CdLS

TRACnet In operation TRAC PLUS/MOH

HMIS In operation MOH

Bilateral coordination meetings In operation Bilaterals

– 89 –

tAbLe 4.2.1M&e system – 2005 M&e system– 2008

Component 1: organizational structure for national, sub-national and service delivery level M&e

CNLS was in place as well as provincial HIV committees. The M&E system was not decentralized at the district level. Under the lead of the CNLS, the national M&E working participated to the review of the NSP 2002-06, the development of the NSP 2005-09 and of the current M&E Plan.

CNLS monitors all non-health aspects of the epidemic while the health aspects are monitored by TRAC Plus. The organizational structure at the district level is well designed, particularly for civil society implementers. Though M&E staff responsibilities are overall clearly defined, there are not enough M&E human resources, in particular at district and sector levels. Moreover, there is a need to ensure that HIV interventions under all EdPRS sectors are monitored and captured by the existing National M&E system. Although M&E guidelines exist, there is scope for improvement and adaptation to EdPRS as well as further dissemination.

Component 2: Human capacity for Hiv M&e at the national, sub-national and service delivery level.

There was an M&E department with dedicated staff. A system to strengthen capacity was in place and functional.

Overall, M&E staff responsibilities are clearly defined and persons conducting M&E duties have minimum requirements. However, there is a lack of human capacity in both quantity and skills, in particular at the decentralized level and within sectors. There is need to develop a standardized M&E training curriculum that includes M&E system and tools at national and decentralized levels and provide training to staff and partners.

Component 3: M&e partnerships to plan, coordinate and manage the M&e system (national, sub-national & service delivery levels)

The national M&E technical working group (TWG) was meeting regularly. To improve coherence, the group was also covering planning issues and it became: the PM&E TWG.

There is a national Planning and M&E TWG led by CNLS and including TRAC Plus and key international and national partners. The PM&E TWG provides technical support and works at improving harmonization of donors to the national system. There is still need to improve the functioning of the group through regular meetings; improve the overall communication at both national and sub-national levels and create an updated inventory of M&E stakeholders. HIV district committees coordinating the overall HIV response at the district level meet regularly and cover M&E issues as well. There are no district M&E groups per se. A strong need has been identified at district level for data analysis and data use for better planning.

Component 4: national M&e framework to measure the status of the Hiv response

There was a NSP for 2005-09 (the object of this review) but there was not a national M&E plan. The National M&E was developed in 2006, after the NSP was finalized.

There is a national M&E plan for 2006-2009. Stakeholders at all levels participated to its development. The plan will be revised for coherence with the new NSP and the EdPRS framework in 2009. As part of the revision there is a need to review and harmonize the indicators at national level (across sectors) and sub-national levels; to define baselines; clarify data collection mechanisms and frequency and set targets. The new M&E Plan will be included into the new NSP.

Component 5: Costed M&e work plan

In 2005 there was not an annual costed plan to monitor the HIV response.

Activities in the national M&E work plan 2006-2009 are costed but do not include all 12 components of a functional M&E system. An integrated, costed M&E Road Map for the country to determine funding gaps and submit to donors has been developed end 2007 but is not yet in use. The ongoing process to review the NSP and M&E plan should allow an updating and use of the Road Map.

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M&e system – 2005 M&e system– 2008

Components 6: Hiv M&e advocacy, communications and culture

Advocacy, communication and M&E culture were weak at the time.

A culture of M&E exists and is getting stronger. Several advocacy activities with sectors at district level, with civil society/umbrellas and donors are conducted. However, an M&E formal advocacy strategy as such does not exist. HIV stakeholders demonstrate commitment to M&E. However, communication regarding the M&E system performance is not regular, particularly at sub-national level. HIV stakeholders should create additional M&E positions, share information and allocate resources to fully demonstrate commitment to M&E.

Component 7: Surveys and Surveillance

The R-dHS was carried out in 2005 and included an HIV component. Around the same period, a BSS (including sex workers, truck drivers and youth) was carried out by TRAC Plus. A system of ANC sentinel surveillance was also in place. An additional study on the cost of treatment and care for PLWHA was conducted in 2006.

Surveys and surveillance have standard protocols in line with international guidelines and are carried out per recommendations. Suggested strengthening measures are: capacity building for improved quality (and reduced biases from surveys), resource mobilization to generate more funds to conduct surveys and the creation of better linkages with indicators in the national M&E plan. If the system is well advanced for the general population, surveys for most-at-risk populations need strengthening.

Components 8: Routine program Monitoring

In 2006 a unique system of planning and reporting was put in place from the decentralized level (CdLS) to the national level (CNLS). An electronic database (CNLSnet) was developed for this purpose. data from partners are collected by CdLS TAs and sent to CNLS. Clinical data are collected by TRAC Plus through TRACnet, CAMERWA, and MOH through their HMIS system called SIS.

As per the system put in place since 2006, a national guide defines standard planning and reporting tools and procedures down to the district level. Each district consolidates annual plans and quarterly reports from all partners operating in the district into a standard template and transmits this through the web to a national database (CNLSnet), allowing a national overview of planning, implementation and financial resources at district and national level. CNLS consolidates a mid-year report and a national annual HIV monitoring and evaluation report. Therefore, reporting tools are standardized, known and used by partners. Substantial improvements (see Component 9) were made to the database in 2008. However, there is not systematic feedback mechanism, in particular at the sub-national level and there is lack of systematic data verification for instance for beneficiaries of services and OVCs. Recommended measures are to strengthen data collection and reporting at community level and strengthen the feedback mechanism related to routine HIV program monitoring. The Routine HIV program monitoring for the health sector is well established and functioning.

Component 9: national and Local Hiv Databases

CNLSnet was designed and its installation started in 2006. The database does not include clinical HIV data (collected through a different system by TRAC Plus).

There is a functional web based database for capturing and storing data generated by the HIV M&E system at the decentralized level (CNLSnet) and a web database for collection of ARV site data - clinical, laboratory and drug stock monitoring (TRACnet). Substantial improvements were made to CNLSnet in 2008. Among the new features of the database there is the possibility to produce automatic summary reports with diagrams and maps for all the data variables (geographic area, domain and type of intervention, implementing partners, beneficiaries, progress indicators, source of funding, budget spent). No mechanisms exist so far for linking HIV data from different databases (such as the education sector database). Recommended measures are to create linkages between relevant databases, but ensure that confidentiality is maintained.

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M&e system – 2005 M&e system– 2008

Component 10: Supportive Supervision and Data Auditing

Since 2005 a data audit to monitor data quality of partners is carried out. The audit was done once a year and relative reports are produced by CNLS.

To ensure and maintain data quality, CNLS carries out joint quarterly field supervision together with other national institutions involved in the response to the epidemic, such as donors, civil society, coordinating bodies and NGOs. Joint national reviews of the HIV response also take place regularly. However, there is little feedback provided after supervision and there is no auditing system in place at decentralized level. Standardized guidelines for supervision and data auditing should be developed, particularly for the sub-national level and the feedback mechanism improved.

Component 11: Hiv evaluation, research and learning agenda

An HIV and AIdS Research Committee led by CNLS is in place since 2006. The committee reviews, orients, evaluates and approves all HIV research protocols in the country. The committee ensures that research protocols respond to the needs of the country and avoid duplications. The committee meets once a month.

The HIV and AIdS Research Committee lead by the CNLS is assigned the responsibility of coordinating HIV research and evaluation. In 2008 the committee finalized a national guide on research coordination in the country. Joint reviews of the HIV response in Rwanda take place periodically. Recommended strengthening measures are to disseminate the national research guide; identify research priorities and mobilize the necessary funding; and strengthen the functioning of the HIV and AIdS Research Committee (for instance by providing incentives for stronger engagement of members). Much of the HIV research related to Rwanda is available online through a “Virtual Library”.

Component 12: Data Dissemination and information Use

Overall, data sharing and data use are not effective. However, CNLS produces regular reports. Also, the annual research conference allows sharing of some research findings.

There is still inadequate data analysis and data use for decision making. Also, reporting at times is a problem in terms of quality, timeliness and meeting information requirements of different stakeholders. There is need to enhance the capacity of end data users to more effectively utilize the results from M&E and operational research and to feed back into planning and service delivery. Major gaps in data use are at the district level.

tAbLe 4.3.1: bReAKDown bY SpenDinG CAteGoRY in 2005, 2006, 2007 AnD 2008 Spending category by nSp Axis

indicative expenditures 2005

Real amount spent 2006

indicative budgets/declared expenditures 2007

indicative budgets/declared exp. 2008

Prevention programs 19,694,545 20,944,419 35,461,168 41,415,987

Treatment and care components 31,674,758 27,227,955 75,923,495 115,271,517

Coordination 20,019,669 26,524,292 16,813,456 22,667,158

Impact Mitigation 11,536,992 12,708,434 13,755,288 16,635,219

Surveillance 2,068,661 486,880 0*** 0***

Total 84,994,625 87,891,981 141,953,407** 195,989,881**

Exchange rate 2005: 1$ = 550 Rwf, Exchange rate 2006: 1$ = 551.74 RwF. 2005 data were adjusted to 2006 real RwF accounting for inflation.**district budgets were excluded from the totals to avoid double counting*** This should not be interpreted that there was no funding for epidemiological surveillance, but that this funding is often classified within the traditional domains of prevention and care and treatment, as appropriate.

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– 93 –

RefeRenCeS

1. Centre for Economic and Social Studies (UNICEF, MiniYouth, CNJR). Etude sur les connaissances, attitudes, pratiques et comportements des jeunes de 10-24 ans en matière de VIH et SIDA au Rwanda 2007. Kigali, Rwanda: Centre for Economic and Social Studies; 2008.

2. CHF International Rwanda. Annual Activity Report 2007. Kigali, Rwanda: CHF International Rwanda; 2008.

3. Global Fund to Fight AIDS, TB and Malaria. Rwanda RWN-607-G08-H Grant Performance Report. Geneva, Switzerland: Global Fund to Fight AIDS, TB and Malaria; 2008.

4. Institut National de la Statistique du Rwanda (INSR) and ORC Macro. Rwanda Demographic and Health Survey 2005. Calverton, MD: INSR and ORC Macro; 2006.

5. John Snow, Inc. Condom Programming for Rwanda: Report of a Rapid Situational Analysis. Kigali, Rwanda: John Snow, Inc.; 2008.

6. Koster M, Price L. Rwandan female genital modification: Elongation of the Labia minora and the use of local botanical species. Culture, Health & Sexuality. 2008; 10(2):191-204.

7. Mission of Hope Rwanda. Etude sur l'identification, l'analyse des comportements des travailleuses du sexe face au VIH&SIDA et l'accès au service de santé dans les districts de Nyarugur, Rusizi et Rubavu au Rwanda. Kigali, Rwanda: Mission of Hope Rwanda; 2008.

8. National AIDS Control Commission of Rwanda. 2008 HIV and AIDS Epidemiological Update. Kigali, Rwanda: National AIDS Control Commission; 2008.

9. National AIDS Control Commission of Rwanda. Annual report on the implementation of HIV and AIDS activities 2006. Kigali, Rwanda: National AIDS Control Commission; 2007.

10. National AIDS Control Commission of Rwanda. Cadre Stratégique National du Rwanda en Communication pour le Changement de Comportements en matière du VIH/SIDA/IST 2005-2009. Kigali, Rwanda: National AIDS Control Commission; 2004.

11. National AIDS Control Commission of Rwanda and UNAIDS Rwanda. Country Harmonization and Alignment Tool Final Report. Kigali, Rwanda: National AIDS Control Commission; 2008.

12. National AIDS Control Commission of Rwanda. Etude sur les Priorités Locales pour les Efforts de Lutte Contre le SIDA (PLACE). Kigali, Rwanda: National AIDS Control Commission; 2006.

13. National AIDS Control Commission of Rwanda. Evaluation de la mise en œuvre des programs et du Guide Opérationnel CCC et matrices CCC concernant les veuves et les personnes handicappées. Kigali, Rwanda: National AIDS Control Commission of Rwanda; 2007.

14. National AIDS Control Commission of Rwanda. Guide Opérationnel National pour la mise en oeuvre des programs CCC en matière de lutte contre le VIH/SIDA auprès des groupes cibles prioritaires. Kigali, Rwanda: National AIDS Control Commission; 2006.

15. National AIDS Control Commission of Rwanda. Integrating HIV into the Economic Development and Poverty Reduction Strategy 2008-2012: Rwanda’s Experience. Kigali, Rwanda: National AIDS Control Commission of Rwanda; 2008.

16. National AIDS Control Commission of Rwanda. Module de Formation en Suivi et Evaluation des Programs VIH et SIDA au Niveau Communautaire. Kigali, Rwanda: National AIDS Control Commission of Rwanda; 2006.

– 94 –

17. National AIDS Control Commission of Rwanda. National Condom Policy. Kigali, Rwanda: National AIDS Control Commission; 2005.

18. National AIDS Control Commission of Rwanda. Plan National de Prévention du VIH 2005-2009. 2nd ed. Kigali, Rwanda: National AIDS Control Commission; 2006.

19. National AIDS Control Commission of Rwanda. Plan Stratégique National Multisectoriel de Lutte contre le VIH et le SIDA 2005-2009. Kigali, Rwanda: National AIDS Control Commission; 2005.

20. National AIDS Control Commission of Rwanda. Rapport annuel des activités de la CNLS 2006. Kigali, Rwanda: National AIDS Control Commission; 2007.

21. National AIDS Control Commission of Rwanda. Rapport annuel des activités du Secrétariat Exécutif de la CNLS 2007. Kigali, Rwanda: National AIDS Control Commission; 2008.

22. National AIDS Control Commission of Rwanda. Rapport annuel de lutte contre le Sida 2007. Kigali, Rwanda: National AIDS Control Commission; 2008.

23. National AIDS Control Commission of Rwanda. Rwanda National HIV and AIDS Monitoring and Evaluation Plan 2006-2009 Part 1: Systems and Framework. Kigali, Rwanda: National AIDS Control Commission; 2006.

24. National AIDS Control Commission of Rwanda and UNAIDS Rwanda. United Nations General Assembly Special Session (UNGASS) on HIV/AIDS: Rwanda Country Report 2006-7. Kigali, Rwanda: National AIDS Control Commission of Rwanda; 2008.

25. Rwanda Ministry of Health. Annual report 2006. Kigali, Rwanda: Rwanda Ministry of Health; 2007.

26. Rwanda Ministry of Health. Annual report 2007. Kigali, Rwanda: Rwanda Ministry of Health; 2008.

27. Rwanda Ministry of Health. National Standards and Directives for the Voluntary Counseling and Testing and Prevention of Mother to Child Transmission of HIV/AIDS. Kigali, Rwanda: Rwanda Ministry of Health; 2008.

28. SMART Consultancy Ltd. Enquête national sur la disponibilité et l'accessibilité du condom masculin au Rwanda. Kigali, Rwanda: SMART Consultancy Ltd; 2005.

29. TRAC Plus. Enquête de surveillance des comportements relatif au VIH/SIDA (BSS) auprès des jeunes, des professionnelles de sexe et des transporteurs routiers au Rwanda (2000 & 2006). Kigali, Rwanda: TRAC Plus; 2006.

30. TRAC Plus. Manual: Triangulation Training Worskhop for Analysis and Use of Strategic Information. Kigali, Rwanda: TRAC Plus; 2008.

31. TRAC Plus. National Care and Treatment Plan 2003-2007. Kigali, Rwanda: TRAC Plus; 2003.

32. TRAC Plus. Preliminary ANC data 2007. Kigali, Rwanda: TRAC Plus; 2007.

33. TRAC Plus. Rapport annuel du TRAC Plus 2006. Kigali, Rwanda: TRAC Plus; 2007.

34. TRAC Plus. Rapport annuel du TRAC Plus 2007. Kigali, Rwanda: TRAC Plus; 2008.

35. TRAC Plus. Surveillance de l'infection à VIH par sites sentinelles chez les femmes enceintes fréquentant les services de consultation prénatale. Kigali, Rwanda: TRAC Plus; 2005.

36. TRAC Plus. Surveillance Epidémiologique et Lutte Contre la Maladie au Rwanda: Guide Technique au niveau du District. Kigali, Rwanda: TRAC Plus; 2006.

37. Underhill K, Montgomery P, Operario D. Sexual abstinence only programs to prevent HIV infection in high income countries: systematic review. BMJ. 2007:335-248.

– 95 –

38. Unité de Gestion des Projets MAP et Global Fund. Rapport d'activités de l'UGP des projets financés par le Fonds Mondial: Exercice 2006. Kigali, Rwanda: Unité de Gestion des Projets MAP et Global Fund; 2007.

39. Unité de Gestion des Projets MAP et Global Fund. Rapport d'activités de l'UGP des projets financés par le Fonds Mondial: Exercice 2007. Kigali, Rwanda: Unité de Gestion des Projets MAP et Global Fund; 2008.

40. Unité de Gestion des Projets MAP et Global Fund. Rapport du premier semestre 2008 (Fonds Mondial). Kigali, Rwanda: Unité de Gestion des Projets MAP et Global Fund; 2008.

41. Unité de Gestion des Projets Map et Global Fund. Projet Multisectoriel de Lutte contre le Sida (MAP) Don IDA H 029 RW. Rapport Annuel Année 2006. Kigali, Rwanda: Unité de Gestion des Projets MAP et Global Fund; 2007.

42. Unité de Gestion des Projets MAP et Global Fund. Projet Multisectoriel de Lutte contre le Sida (MAP) DONS IDA H 029 — RW et H 271 0 — RW. Rapport Annuel 2007. Unité de Gestion des Projets MAP et Global Fund; 2008.

43. Unité de Gestion des Projets MAP et Global Fund. Projet Multisectoriel de Lutte contre le Sida (MAP) DONS IDA H 029 — RW et H 271 0 — RW. Rapport Semestriel période: Janvier-Juin 2008. Kigali, Rwanda: Unité de Gestion des Projets MAP et Global Fund; 2008.

44. US Embassy in Rwanda. Annual Progress Report Fiscal Year 2006. Kigali, Rwanda: US Embassy in Rwanda; 2007.

45. US Embassy in Rwanda. Annual Progress Report Fiscal Year 2007. Kigali, Rwanda: US Embassy in Rwanda; 2008.

46. US Embassy in Rwanda. Program Level Indicators Report FY 2006. Kigali, Rwanda: US Embassy in Rwanda; 2007.

47. US Embassy in Rwanda. Semi-Annual Progress Report Fiscal Year 2008. Kigali, Rwanda: US Embassy in Rwanda; 2008.

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AnneX 1: KeY qUeStionS

The key questions were developed by analysing the data required for outputs and outcome indicators. The questions guided data collection and analysis processes at all stages of the review. Outcome level questions sought to identify changes that had taken place within key institutions delivering health services and at com-munity level as a result of the outputs achieved by the NSP. Output level review focused on the relevance and appropriateness of the strategies used to implement various initiatives and the key achievements of these initiatives.

The following basis questions guided the review at output level:

• What initiatives were planned under each output?• What progress has been made under each output? • What are the key achievements under each

output?• What constraints were experienced under each

output?• What are the key gaps or areas that are not

adequately addressed?• Did the initiatives implemented under each

output area address the right issues, target the right groups using appropriate strategies?

In addition to these basis questions, key questions spe-cific to each outcome and output are identified below:

KeY qUeStionS foR AXiS 1: pRevention of Hiv infeCtionS nSp objective Key questions

outcome 1

High risk sexual behavior change

• What has been the change from the 2005 baseline of » % of adults aged 15-24 reporting sex with more than one partner in the last 12 months » % of adults aged 24-49 who had more than one sexual partner in the last 12 months

reporting use condom use• Are sexual behaviour change programmes addressing relevant drivers of high-risk

behaviour? • Are the programmes targeting the relevant populations?

Latest RDHS was done in 2005 which formed the baseline for this NSP. BSS 2006 provide more recent data. Additional small scale surveys targeted at different groups can also provide data on behaviour change. The Focus Group Discussions will provide information on the extent to which sexual behaviour may have changed.

outputs

output 1.1Promote EABC through IEC

• How is EABC coordinated? Is there a national IEC/BCC strategy and guidelines?• What IEC Programmes were implemented? Where and who was targeted?

» How many people were trained to sensitize on EAB? » Were most at risk groups targeted? » Were the minority groups – people with disabilities targeted?

• How many people were reached by IEC programmes? • How were the IEC messages received by the targeted groups?

» What types of messages were delivered? » Did the target group find the messages appropriate? » Did the messages influence the sexual behaviour of the target groups in terms of

abstinence, being faithful or using a condom? » Did the IEC programmes increase the target groups’ knowledge on HIV prevention?

• What challenges are facing IEC programmes promoting EABC?

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output 2Increase access to and use of condoms

• What condom promotion programmes are being implemented? » What is the number of male condoms distributed? » What is the number of female condoms distributed? » What types of groups were targeted for condom distribution? » Which implementers are involved in condom distribution? » What was the geographical coverage of condom distribution

• What are the challenges facing the condom promotion programmes? • What are the obstacles hindering accessing female condoms?• What are the obstacles in accessing male condoms?

It will not be feasible to get data on use of condoms. Views on use of condoms cab be solicited from focus groups.

output 3Educate youth on sexual responsibility

• Is the sex education curriculum available?• How many schools were provided sex education curriculum?• How many schools/teachers were trained in implementation of the sex education

curriculum?• What challenges are facing the implementation the sex education programmes?

This strategy is being implemented by Ministry of Education through the school system.

output 1.4Increase the number of people in the population that know their IV serological status

• How many VCT sites are in place disaggregated by geographical distribution and sector against what was planned?

• How many people were tested for HIV disaggregated by age, sex, geographical distribution and by vulnerable against what was planned?

• Are the CT centres applying the CT guidelines? • What challenges are facing the delivery of CT services?

output 1.5Increase the proportion of population that knows causes, symptoms and consequences of STI, OI and TB

• What was the strategy for achieving this output?• What programmes were implemented? Where? Who was targeted?• What are the challenges in achieving this output?

It is not clear how this output was defined – knowledge of causes, symptoms and consequences of OIs does not seem to be feasible a strategy.

outcome 2

Change the behaviour of health providers to reduce the STI, TB and HIV transmission

• What is the % or number of health facilities implementing universal precautions?• What is the % or number of health facilities implementing provider initiated diagnosis

of STIs, OIs and TB?

outputs

output 2.1Adopt universal precaution in health care related establishments

Covered under Care and Treatment

output 2.2Adopt provider initiated diagnosis of STIs, OIs and TB


output 2.3Adopt safety measures


– 100 –

outcome 3

Reduce the HIV transmission by medical prophylaxis

• What % of pregnant HIV+ women attending ANC/PMTCT receives medical prophylaxis?

• How effective is the access of PMTCT services by pregnant women?• How effective is the access of PEP services by health care personnel?• How effective is the access of PEP services by rape victims?

outputs

output 3.1Motivate pregnant women and their partners to use PMTCT services


output 3.2Increase access to high quality PMTCT services


output 3.3Assure PEP for health care personnel


output 3.4Assure PEP for rape victims


outcome 4

Create a cultural environment more favourable to preventing HIV/STI transmission

• What is the extent to which communities are promoting positive cultures that prevent HIV transmission?

• What is the extent to which communities are abandoning negative cultures that accelerate the transmission of HIV?

outputs

output 4.1Promote the retention of Rwanda cultural practices that constitute to preventing HIV/STI transmission

• What strategy was adopted to achieve this output?• What programmes were implemented?• What cultural practices were targeted?• What are the challenges facing cultural promotion programmes?

output 4.2Promote abandoning of Rwandan negative cultural practices that contribute to HIV and other STIs

• What strategy was adopted to achieve this output?• What programmes were implemented?• What cultural practices were targeted?• What challenges are facing the abandonment of negative cultural practices?

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KeY qUeStionS foR AXiS 2: ReSeARCH AnD SURveiLLAnCe nSp objective Key questions

outcome 1

Increase the usefulness of surveillance results with respect to the national response to HIV/AIdS

• What are the key achievements and constraints in Surveillance?

• How have the surveillance results been used to improve HIV and AIdS response?

outputs

output 1.1Improve national systems for case notification of morbidity and mortality related to AIdS

• What is the rate of notification? How many cases are notified each year – 2005, 2006, 2007, 2008?

• Is the information complete? It is reliable?• How many FOSA are reporting out of the total?

output 1.2Establish a sustainable behavioral surveillance system

How well is the system working?What has been done to make it sustainable?

output 1.3Improve HIV sero- surveillance by including other HIV/AIdS-related diseases

• How many sero-surveillance sites are functioning? • What is the coverage of sero-surveillance? Provinces/

district

output 1.4Improve the statistical and analytical competencies of surveillance technicians

• How many statistical technicians have been trained? By province and district or by surveillance site

• Has reporting improved?

outcome 2

Increase the usefulness of research results, studies and evaluation with respect to the national response to HIV/AIdS

• How have research findings improved the national HIV and AIdS response

outputs

output 2.1Improve the methodological competencies of researchersoutput 2.2Improve the statistical and analytical competencies of researchers output 2.3Involve people to be studies in the identification, design and execution of research

• Were the planned trainings carried out? How many people were trained?

• How were researchers identified? • How many research projects were carried out? • How were research projects identified? • What process was used to involve “people to be studied”

in the research?

Research committee • Is there an HIV and AIdS research committee? • How many times does it meet?• What are its terms of reference?• How have they executed their terms of reference?

outcome 3

Improve the ability of stakeholders to interpret and use surveillance and research results

• What has been done to improve stakeholders’ capacity to use research results?

Need to find out the extent to which research and surveillance results have been use to improve HIV and AIDS initiatives.

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outputs

outputs 3.1promote and facilitate the routine availability of surveillance results output 3.2Improve analytical capacity of all levels of beneficiaries and decision makersoutput 3.3Strengthen the capacity of technicians and stakeholders to present results in various more usable format

• What is the capacity of the surveillance system?• What is working well and what is not?

AXiS 3 KeY qUeStionS nSp objective Key questions

impact

Improve treatment, care and support for persons infected and affected by HIV and AIdS

• What is the % of people alive 12 months after starting treatment

Data source• TRAC+ (ART Treatment data)

outcome 1

Access to quality care and treatment at health facilities

• What is the % of people on ART program? disaggregated by age, sex and geographical distribution (show annual figures)

outputs

output 1.1Assure equitable coverage of ART services with emphasis on pediatric care

• Are the ART guidelines/protocols in place? Are these guidelines/ protocols being followed at health facility level? Are the guidelines comprehensive?

• Are health care personnel trained on the implementation of ART guidelines?• What is the number of people on ART program? disaggregated by age, sex and

geographical distribution • What is the rate of drop out/loss of patients on ART annually? disaggregated by

site, age and sex. • What are the reasons for drop/loss of patients?• What is the number of health facilities providing ART services? by province/

district; by pediatric and adult ART services• What is the capacity of the health care system to provide ART services?

output 2Improve treatment of OIs according to national norms and protocols

• Are the national norms and protocols in place? Are these protocols covering all the key areas?

• Are health care personnel trained on use of the protocols?• Are the norms and protocols being followed?

output 3Reduce the real cost of accessing HIV and AIdS related care and treatment

This output lacks clarity. There is need to find out how this output was to be achieved. What specific activities have been carried out to reduce the real cost of HIV and AIdS related treatment.

output 1.4Promote provider initiated diagnosis approach

• Are provider initiated diagnosis guidelines/protocols in place? • Have health personnel been trained on the guidelines?• How many of the health facilities are implementing provider initiated diagnosis

of HIV?

Coverage of this service by province/district

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output 1.5Improve collaboration and service referrals between health care providers and community agents

• Are there guidelines for the health facility-community agents collaboration?• Have health personnel and community agents been trained on community

based health care?• Is HIV/AIdS integrated in this community health care system? What specific HIV

and AIdS services are community agents delivering? • How often do the health personnel and community agents meet?• What support is provided to community agents?• What is the performance of the community agents?• What is the drop rate of the community agents?• What are the challenges facing use of community agents to deliver HIV and AIdS

services?

output 6Improve therapeutic nutrition support for people on ART

• What is the national policy on nutritional support for people on ART?• Were the health personnel trained to implement nutrition policy/guidelines?• How many health facilities are providing therapeutic nutritional support to in-

patients on ART?• How many health facilities were supplied with nutritional support equipment?

output 7Integrate care and treatment of OIs among other illnesses supported through CBHI

• Which OIs were expected to be integrated?• Have these OIs been covered by CBHI?• What is the utilisation rate of the insurance cover for these OIs?

output 8Strengthen health care providers’ capacity to deliver highest quality of HIV? care

• What type of training was provided to health care personnel?• How many personnel have been trained?• What quality assurance system is in place? How is the system implemented?• What are the challenges facing delivery of quality health care?

outcome 2

Increase access to high quality community based care and treatment

• What is the % of households receiving the minimum community health based package? (Coverage)

• What are the policy guidelines for community based care and treatment

outputs

output 2.1Assure equitable coverage of community based care and treatment services

• What was the strategy for achieving this output?• What is the coverage of the CB care and treatment services?

output 2.2Improve the CB care and treatment of PLWHAs

• What was the strategy for achieving this output? What was being improved?• What progress has been made in addressing the weaknesses in CB care and

treatment identified in 2005? • What challenges are facing the provision of community health care and

treatment services?

output 2.3Strengthen the technical capacity of people and organisations providing care and support

• What was the strategy for achieving this output?• What type of training took place?• How many people/organisations were trained by province/district?

output 2.4Integrate home based care and treatment for PLWHAs within community based services

• How has HBC for PLWHAs been integrated into CB services?• How is the integrated service being provided?• What challenges are facing integration of HIV services in CB services?

output 2.5develop and standardize outpatient and mobile treatment services

• Where these services developed? Are the policy guidelines in place?• What is the coverage of these services? per province/district and people reached• How are the mobile services implemented?• What challenges is the mobile service facing?

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output 2.6Improve the nutritional status of people infected and affected by HIV and AIdS?

• How many households are provided with food? Is there a register? Assess the coverage of this service by province and district; show annual figures

• How are the households identified? • How is the food supplied?• What challenges are facing the nutritional support programme?

outcome 3

Assure that HIV and AIdS related care and treatment is sustainable

• Is there a national HIV and AIdS care and treatment sustainability plan in place?• What progress had been made in implementing this plan?

outputs

output 3.1Improve decentralized HIV and AIdS related procurement, management and distribution system

• Is a decentralized system for procurement and distribution of care and treatment products in place? How is the system designed? What challenges is the system facing?

• Is a decentralization system for management of HIV and AIdS care and treatment in place? How is it designed? What challenges is it facing?

output 3.2Increase Rwandan human resources needed for HIV and AIdS related care and treatment

• How many staff were to be recruited and how many have been recruited by 2008? disaggregated by category, province and district since 2005? Show annual figures if available or compare 2005 with current levels of personnel. This can only be assessed if secondary data is available.

output 3.3Establish a system to supply communities with required materials

• Which materials were to be supplied? • Is the system for supply of materials in place?• How is this system functioning?• What challenges is the system facing?

output 3.4Execute a national plan to assure that the expanded global care and treatment is sustainable

• Is there a national sustainability plan for care and treatment of HIV and AIdS?• What progress had been made in implementing this plan?

Hiv prevention

outcome 2

Change the behaviour of health providers to reduce the STI, TB and HIV transmission

• What was the plan to change the behavior of health providers to reduce HIV, STI and TB? Was this plan implemented??

• What is the % of health facilities implementing this behavioral change• What are the challenges?• What is the % or number of health facilities implementing provider initiated

diagnosis of STIs, OIs and TB?

outputs

output 2.1Adopt universal precaution in health care related establishments

• Are there guidelines for universal precautions?• Were health personnel trained on universal precautions?• How many health facilities have adopted universal precautions services?• What challenges are facing implementation of universal precautions?

output 2.2Adopt provider initiated diagnosis of STIs, OIs and TB

• What was the strategy for achieving this output?• Are guidelines for provider initiated diagnosis in place?• What had been done to adopt provider initiated diagnosis?• What challenges are facing the provision of this service?

output 2.3Adopt safety measures

•Whatwasthestrategyforachievingthisoutput?•Whatsafetymeasureshavebeenadoptedsince2005?•What%ofbloodunitshavebeenscreenedforHIV?Showannualfigures•WhatchallengesarefacingscreeningofbloodforHIV?

– 105 –

outcome 3

Reduce the HIV transmission by medical prophylaxis

• What % of pregnant HIV+ women attending ANC/PMTCT receives media prophylaxis?

• How effective is the access of PMTCT services by pregnant women?• How effective is the access of PEP services by health care personnel?• How effective is the access of PEP services by rape victims?

outputs

output 3.1Motivate pregnant women and their partners to use PMTCT services

• What motivation was given to pregnant women to use PMTCT services? • What challenges are facing the motivation of pregnant women?

output 3.2Increase access to high quality PMTCT services

• What has been done to increase access to PMTCT services?• How many PMTCT sites have been out in place since 2005?• How many pregnant women have been provided with PMTCT services annually

since 2005?

output 3.3Assure PEP for health care personnel

• What has been done to provide PEP for health personnel?• How many personnel have been provided with this service?• What challenges are facing provision of PEP services for health personnel?

output 3.4Assure PEP for rape victims

• What has been done to provide PEP for rape victims?• How many rape victims have been provided with this service?• What challenges are facing provision of PEP services for rape victims?

AXiS 4: iMpACt MitiGAtion nSp objective Key questions

outcome 1

Improve the social economic condition in Rwanda • Are the impact mitigation programmes improving the lives of the people affected and infected by HIV and AIdS?

outputs

output 1.1Create employment opportunities for vulnerable groups

• What was planned and what had been done? • What vulnerable groups were targeted? • How many people have been reached? = men and women• What type of employment opportunities have been created?• Challenges and constraints?• How much funding has been provided to targeted groups?

output 1.2Assure access to credit for vulnerable groups

• Which vulnerable groups were targeted?• What was planned and what has been done?• What are the achievements and constraints?

output 1.3Improve equity and equality for men and women for IGAoutput 1.4Improve access to formal and informal education for target groups with emphasis on OVCs and PLWHAs

• What was planned and what has been done?• What has been achieved and what are the constraints?• How many OCVs and PLWHAs have been supported to access

education?

outcome 2

define and promote human rights • How many court cases claiming violation of human rights have bee registered annually and by province and district?

– 106 –

outputs

output 2.1Improve the legal framework for PLWHAs and OVCs

• What was planned and what has been done?• Which laws have been revised?

output 2.2Improve the no. of employers who have adopted HIV work place policy

• How many organisations/institutions have work place HIV policies?

• What type of work place programmes are in place? • What has been achieved as a result of these policies?

output 2.3Protect women against sexual and domestic violence

• What was planned and what has been done?• What are the main achievements?

output 2.4Improve current policies to ensure equitable access to services by PLWHAs and OVCs

• What was planned and what has been done?• Which current policies have been revised?

outcome 3

Strengthen decision making capacities of associations involved in HIV and AIdS (by using GIPA concept)

• What proportion of PLWHAs are members of RRP+? Per province and sex?

outputs

output 3.1Strengthen managerial capacity of associations involved in HIV and AIdS

• How many members have been trained on management of HIV interventions?

• What had been achieved and what are the constraints? (refer to assessment of the RRP+ and interview RRP+ coordinators at district level)

output 3.2Balance the composition of HIV and AIdS related associations

• What is the number of men and women in RRP+ associations?• What is the number of RRP+ members with at least secondary

education? • What is the number of HIV- members in RRP+ associations?

output 3.3Increase involvement of PLWHAs in decision making, planning and implementation and review of programmes

• What was planned and what has been done?• How many (number and percentage) RRP+ associations have

been transformed into cooperatives? • What is the process adopted in implementing GIPA?• What have been achieved?• What are the constraints?

AXiS 5: CooRDinAtion objective Key questions

outcome 1

Improve the capacities of National HIV/AIdS coordination structures

• What improvements in the coordination of the mutli-sectoral response have taken place over the last three years?

• How well are the decentralized structures working?• What is the capacity of these coordinating structures to play their roles

effectively?

What are the achievements and constraints facing the private, civil society and public sector responses?

– 107 –

outputs

1.1Strengthen leadership capacity of personnel

• What is the capacity of the coordinating organisations to offer leadership in planning, M&E, reporting, communication and ensuring effective harmonization and alignment of the national HIV and AIdS response?

1.2Strengthen administrative and managerial capacity of institutions

• What administrative and managerial capacity building has been done over the last three years?

• What improvements have been made in the administration and management of the coordinating institutions

1.3Assure that necessary resources for operations are available for coordinating structures

• What is the funding level for the coordinating institutions?• How sustainable is funding for these organisations?

1.4Harmonize the directives and communications across all intervention domains

• What system has been put in place to ensure harmonization of the HIV and AIdS interventions over the last three years?

• How well has this system worked?

outcome 2


• What system was put in place to ensure the strategies in national sector plans were implemented?

• What process was applied in developing, implementing, monitoring and reporting on these plans?

The review should emphasize on public sector plans especially those developed by various ministries

outputs

2.1develop and disseminate approaches and methods for integrating HIV/AIdS into national sector plans

• What has been done to integrate HIV and AIdS into national sector plans?

• How effective is this integration? What is working and what is not?

2.2Assure that leaders advocate for integrating HIV/AIdS in each sector

• What advocacy has been done to integrate HIV and AIdS in each sector?

• How many sectors have integrated HIV and AIdS in their plans?• Need to emphasize the integration through public sector planning

2.3Establish an awards mechanism ceremony for best interventions and agencies in each sector

• Is the award system in place? What has been achieved through this system?

outcome 3

Increase HIV/AIdS related Regional activities that are jointly executed

• How are the regional initiatives contributing to the achievements of the NSP?

outputs

3.1Harmonize the regional HIV/AIdS frameworks and documents

• Which regional initiatives have been harmonized with the NSP? • How are these initiatives implemented?

3.2Assure that jointly developed cross-border HIV/AIdS activity plans are executed

• What has been achieved by regional initiatives?• What constraints face the implementation of the regional initiatives?

3.3Make available necessary resources (funds) for the execution of regional HIV/AIdS interventions

• What is the level of funding for regional initiatives within Rwanda?• What aspects of the regional initiatives are not adequately funded?

– 108 –

outcome 4


• How effective is the national M&E framework for the NSP?• How well is this system working at all levels?• How strong is the link between planning, M&E and reporting?

outputs

4.1Simplify and harmonize planning and monitoring tools

• What simplification of planning and M&E tools has been done since 2005?

• How appropriate are the simplified tools?• Has planning and M&E improved as a result of this simplification

process?

4.2The level of details needed for national planning and work plan monitoring is appropriate for national level reporting

• How efficient is reporting by partners to the national level M&E system?

• What is the rate of reporting by partners?• What constraints are facing the reporting system?

4.3Strengthen capacity to facilitate planning and monitoring workshops and meetings

• What capacity building has been done since 2005?• What capacity gaps exist?

4.4Assure that the national HIV/AIdS strategic framework and M&E plan are used by all agencies for activity planning and monitoring

• What is the level of harmonisation and alignment of the HIV and AIdS M&E framework within the three ones principles context?

• What are the constraints facing alignment of the M&E framework?

outcome 5

Jointly evaluate the multi sector response to HIV/AIdS

• What system is in place to ensure joint evaluation of HIV and AIdS initiatives?

• How are joint evaluations coordinated?

outputs

5.1Harmonize and operationalize national indicators, M&E and planning tools

• See section on harmonization of M&E framework under 4.4

5.2Strengthen capacity at all levels to evaluate the national response

• What capacity building has been done on evaluation of the national response?

5.3Jointly develop and validate information products from national evaluation

• Has joint validation of information products taken place over the last three years? Which products have been validated?

5.4Assure that national M&E products are available and useable (Link this output to axis 2)

• What process has been put in place to disseminate M&E products – evaluations, reports and national survey/research findings?

• How effective is this system?

5.5Coordinate research and training

• What research and training coordination system is in place?• How effective is this system? What has been achieved and what are the

constraints?

– 109 –

– 110 –

AnneX 2: DiStRiCtS, foCUS GGRoUp DiSCUSSionS, AnD otHeR ReLevAnt ACtivitieS ConDUCteD in eACH DiStRiCt

District (province) Urban/rural target populations of focus groups Site visits / interviews

Nyarugenge (Kigali) Urban • Prevention » Prisoners (male) » Drivers (male) » Taxi-Moto drivers (male) » Adult women

• Care and treatment » Prisoners on ART

• Impact mitigation » OVC (male) » PLHA (female)

Implementers meeting

Gasabo (Kigali) Urban • Prevention » Out of school youth (male) » Out of school youth (female) » Sex workers (female)

• Treatment » People on ART

• Impact Mitigation » PLHA (female) » OVC (female)

• Implementers meeting

• Visit with Human Rights organizations

Kicukiro (Kigali) Urban • Prevention• Sex workers (female)• Truck drivers (male)• Police (male and female)• Handicapped (male and female)• Treatment

» People on ART• Impact Mitigation

» PLHA/IGA (males) » CHH


Rusizi (Western) Urban • Prevention » Fishermen/women (male and female) » Bar staff (female) » In school youth (male) » In school youth (female) » Out of school youth (male) » Out of school youth (female)

• Treatment » PMTCT clients (already with children)

• Impact Mitigation » PLHA (female)


• CIMERWA cement factory

• district health director• Bugarama health

center staff

– 111 –


Rubavu (Western) Urban • Prevention » Taxi-moto drivers (male) » Taxi drivers (male) » Fishermen (male) » Sex workers (female)


• Impact Mitigation » OVC (female) » PLHA (female)


• Mahoko (“PLACE” site)• Gisenyi (“PLACE” site)• Secondary school• Youth friendly centre• Avocats sans

Frontieres project (Human rights)

Huye (Southern) Urban • Prevention » Bar staff (male) » People living with HIV (female) » Students (male) » Students (female)

• Impact mitigation » Orphans/child household heads/out of

school (male)


• SNdV (Centre for OVC and PLHIV)

• dushishoze centre (PSI youth centre)

• Gako training centre• district health director

Nyaruguru (Southern)

Rural • Prevention » People living with HIV (male) » People living with HIV (female) » Sex workers (female)


• Impact Mitigation » PLHA (male)


Gicumbi (Northern) Urban • Prevention » Refugees (male) » Refugees (female) » People living with HIV (female)

• Treatment » PMTCT clients

• Impact mitigation » Orphans and vulnerable children (female)


• Visit to SAVE violence program

Burera (Northern) Rural • Prevention » Taxi-moto drivers (male) » Youth in school (male) » Youth in school (female) » Disabled

• Treatment » PMTCT clients

• Impact mitigation » PLHA (male) » CHH


• Secondary school site visit

– 112 –


Kirehe (Eastern) Rural • Prevention » Sex workers (female) » Truck drivers (male) » People living with HIV (male)

• Treatment » PMTCT clients » People on ART

• Impact Mitigation » OVC (male)


Nyagatare (Eastern) Urban • Prevention » Out of school youth (male) » Out of school youth (female) » Prisoners

• Treatment » Prisoners on ART (male) » People on ART » PMTCT clients

• Impact Mitigation » PLHA/IGA (female)


– 113 –

– 114 –

AnneX 3: foCUS GRoUp DAtA CoLLeCtion tooL

ConSiGneS SUR LA pRiSe De noteS et Le tRAnSfeRt DeS DonnéeS ReCeUiLLieS DAnS LeS CAnevAS

1. Ce canevas est conçu pour aider les rapporteurs et les facilitateurs des FGD à résumer et présenter les données recueillies dans un format cohérent, à la fin de chaque FGD. Le canevas est à remplir après chaque FGD, de manière collaborative, par les rapporteurs et les facilitateurs.

2. Un canevas devra être rempli pour chaque FGD. Ainsi, s’il y a plus d’un rapporteur dans une FGD, les notes des différents rapporteurs seront consolidées dans un seul canevas qui constituera le rapport « final » de cette discussion.

3. Le canevas permet de résumer les informations de base concernant la conduite du FGD (la date, les participants, la durée etc.) ainsi que les données qui ressortent des discussions des participants.

4. Il est conseillé que les rapporteurs prennent des notes exhaustives durant la discussion. Il n’est pas essentiel de noter la façon précise dont le facilitateur pose des questions. Par contre il est essentiel de capter au maximum les idées et les nuances émises par les participants.

5. Afin de respecter l’anonymat, aucune information pouvant permettre au lecteur de connaitre l’identité des participants ne doit être captée dans les notes ou les canevas.

6. Le facilitateur rendra tous les canevas remplis au « Team Leader » (consultant national). Une fois de retour à Kigali, les Team Leader répartiront les canevas remplis entre eux selon les axes traités.

7. Bien que les guides FGD soient structurés par « thème » il est très probable que les idées des participants ne ressortiront pas dans l’ordre selon lequel les thèmes apparaissent dans le guide. Ce n’est pas grave : d’ailleurs ce sera positif dans la mesure où c’est préférable que les participants influencent la direction de la discussion eux-mêmes. Ainsi, lors du transfert des données dans le canevas, il sera nécessaire de réordonner les notes prises par les rapporteurs. Une technique très facile est d’utiliser des marqueurs

de différentes couleurs (ex. fluorescents) pour marquer avec une couleur différente les notes selon le thème qu’ils concernent. Par la suite il sera facile de savoir quelles notes devront aller dans quelles sections du formulaire. N.B. ce « codage » des notes par couleur devra être fait après la FGD et avant de transférer les notes dans le canevas.

8. Etant donné que les thèmes traités pour chaque axe ne sont pas les mêmes, un canevas différent a été créé pour chaque axe.

9. Si toutes les données pour une FGD n’entrent pas dans une seule page, plusieurs pages peuvent être utilisées et agrafées ensemble.

10. Le canevas est divisé en trois sections :• Section 1: Informations de base sur la FGD.

Dans cette section les rapporteurs résumeront les informations de base sur la conduite de la FGD : la date, les informations sur le lieu, les participants, l’axe traité etc.

• Section 2: Informations recueillies en relation avec chaque thème. Dans cette section les rapporteurs et facilitateurs résumeront les principales données recueillies en relation avec chaque thème discuté durant la FGD, et proposeront les conclusions initiales qui peuvent être tirées par rapport à l’efficacité des programmes ciblant cette la population concernée par le FGD

• Section 3: Impressions des rapporteurs et facilitateurs. Dans cette section les rapporteurs et facilitateurs résumeront leurs impressions générales suite à la FGD et indiqueront quels sont, selon eux, les principales leçons et conclusions à tirer.

11. Etant donné que le volume d’informations collectées changera pour chaque FGD, il est proposé que les rapporteurs et facilitateurs impriment et remplissent une copie de la Section I pour chaque FGD, mais que les sections II et III soient remplis sur des pages vierges qui devront être agrafées (ou fusionnées si le rapport est fait par ordinateur) avec la Section I.

– 115 –

CAnevAS poUR LA CoLLeCte DeS DonnéeS DURAnt LeS fGDSection i : informations de base sur la fGD

date: Population (cocher): � Adultes � Prisonniers � Travailleurs transports en commun � Moto-taxis � Camionneurs/transporteurs � Militaires � Pêcheurs � Bar-man � Jeunes non-scolarisés � Jeunes à l’école � Etudiants � Travailleuses du sexe � Personnes ayant un handicap � Personnes vivant avec le VIH � Personnes sous traitement ARV � Femmes dans le programme PTME � Orphelins/enfants vulnérables � Enfants chefs de ménage � Refugiés

district et ville :

Nom du facilitateur:

Nom(s) du/des rapporteur(s):

1.2.3.

Nombre de participants:

Axe traité (cocher): � Prévention � Prise en charge et traitement

� Mitigation d’impact

Genre (cocher): � Femmes/filles � Hommes/garçons

– 116 –

Section ii : informations recueillies en relation avec chaque thème

Axe 1 Prévention :Thème 1 : Obtention d’informationsThème 2 : Comportements sexuels / prévention du VIHThème 3 : Préservatifs (utilisation et accès)Thème 4 : dépistage du VIH (utilisation et accès)Thème 5 : ISTThème 6 (adultes uniquement) : Attitudes concernant le dialogue entre parents et enfants

Axe 2 Prise en charge et traitement :Thème 1 : Getting on to treatmentThème 2 : How treatment programs are working/operatingThème 3 : Other Types of SupportThème 4 : Changing TreatmentThème 5 : Getting on PMTCTThème 6 : Mothers that already had children under PMTCT

Axe 3 Mitigation d’impact :Thème 1 : Access to creditThème 2 : Human rightsThème 3 : Support for OVCsThème 4 : Sexual violenceThème 5 : decision makingThème 6 : Income generating activities (IGA)

Répondre à toutes ces questions pour chaque thème abordé durant la FGD (traiter un thème à la fois):Thème 1:a. Quelles sont les principales idées ressorties par les participants par rapport à ce thème?b. Est-ce que les participants étaient tous d’accord, ou bien y avait-il des idées divergentes?c. S’il y avait des idées divergentes, quelles étaient les idées soutenues par une majorité (plus que la moitié) des

participants et quelles étaient les idées soutenues par une minorité seulement?d. En ce qui concerne ce thème et cette population, quelles sont les choses positives qu’on peut tirer : qu’est-ce qui

fonctionne bien dans les programmes?e. En ce qui concerne ce thème et cette population, quelles sont les choses négatives qu’on peut tirer : qu’est-ce qui

fonctionne moins bien, ou ne fonctionne pas dans les programmes?Thème 2:[a… etc.]

Section iii: impressions des rapporteurs et facilitateurs

Selon les résultats globaux de cette FGd:a. Quels sont les points forts des programmes menés auprès de cette population?b. Quels sont les points faibles des programmes menés auprès de cette population?c. Quelles sont les principales leçons à tirer et à tenir en compte dans la modification des stratégies auprès de cette

population?

– 117 –

– 118 –

AnneX 4: nAtionAL LeveL KeY infoRMAntS DAtA CoLLeCtion GUiDe

This interview guide will be used to facilitate the in-terviewing of key informants during the review of the National HIV and AIDS Strategic Plan. The questions listed below are not exhaustive. Additional questions should be asked to clarify issues specific to particular outputs and outcomes of the NSP.

1. poLiCY MAKeRSIssues to be discussed should relate to the axis sector the policy maker is leading and additional questions should be asked to clarify issues specific the respective sector.

• What are the major achievements realized under the current NSP?

• What are the major constraints to effective implementation of the NSP? (Constraints to coverage, reach to priority target groups, planning, funding etc)

• How can we make money work better?• How “strategic” is the implementation of the

NSP? (Is it focused on the rights issues, targeting the right groups and using appropriate strategies to achieve results?)

• Which areas of the HIV epidemic are not currently well addressed?

• What should be the key priorities for the 2-3 years?

2. DeveLopMent pARtneRS (poLiCY)Issues to be discussed should relate to the axis the de-velopment partner is supporting. Additional questions should be asked to clarify issues specific to areas the development partner is supporting.

• What is the general progress made since 2005 when the NSP was produced?

• What are the major achievements realized to date in this strategic axis?

• What are the major constraints to effective

implementation of the NSP? (Constraints to coverage, reach to priority target groups, planning, funding etc)

• How “strategic” is the implementation of the NSP? (Is it focused on the rights issues, targeting the right groups and using appropriate strategies to achieve results?)

• Which areas of the HIV epidemic are not currently well addressed?

• What should be the key priorities for the 2-3 years?

3. teCHniCAL eXpeRtS/pRoGRAMMe MAnAGeRS Issues to be discussion should relate to the axis and pro-grammes supported or implemented by the institution. Additional questions should be asked to clarify issues specific to particular output/outcome areas.

• What progress has been made in this area since 2005? (Coverage, target groups, types of initiatives)

• How were these the interventions developed? On what basis have these interventions been developed? (Research, scientific, policy, law etc)

• What are the major achievements in this particular area?

• What are the enabling factors? (New opportunities, support?)

• How strategic are the interventions? Are they focused on the rights people, right issues and using appropriate strategies?

• What are the major constraints facing the interventions?

• What areas of the epidemic are currently not well addressed?

• What should be the key priorities in the next 2 to 3 years

– 119 –

– 120 –

AnneX 5: DiStRiCt LeveL KeY infoRMAntS inteRview GUiDe

This interview guide will be used to facilitate the in-terviewing of key informants during the review of the National HIV and AIDS Strategic Plan. The questions listed below are not exhaustive. Additional questions should be asked to clarify issues specific to particular outputs and outcomes of the NSP.

Issues to be discussion should relate to the implementa-tion of HIV and AIDS programmes at the district level. The discussion, depending on the key informant being interviewed, should focus on all axis.

• What progress has been made in the provision of HIV and AIDS services in the district since 2005? (Coverage within the district, target groups, types of services provided — prevention, care and treatment and impact mitigation)

• How were these the interventions developed? (Find out whether the interventions were designed

from the national level or the local implementing partners identified the interventions themselves and whether beneficiaries are involved in developing interventions)

• Which aspects of the HIV and AIDS interventions have worked well and which ones have not?

• What are the major achievements in providing prevention, care and treatment and impact mitigation HIV and AIDS services in the district since 2005?

• What are the major constraints facing the provision of HIV prevention, care and treatment and impact mitigation services?

• Which services are not adequate? Which areas of the HIV and AIDS epidemic are not well addressed?

• What should be the key priorities that should be addressed in the next 2 to 3 years

– 121 –

– 122 –

AnneX 6: DiStRiCt iMpLeMenteRS’ MeetinG AGenDA

1. pURpoSe of iMpLeMenteRS’ MeetinGSRwanda is reviewing the National HIV and AIDS Plan 2005-2009 to assess the progress made in achieving its objectives, the challenges facing implementation of the plan, lessons learnt and develop recommendations for improvement of the national response to HIV and AIDS. The purpose of the implementers’ meeting is to capture the views of the implementing organisation on their experience in implementing the NSP and their recommendations on improvements that should be made.

The implementers meetings are expected to review the:• General progress made since 2005 when the NSP

was developed• The major achievements realised to date in the

specific areas of the strategic axis? • Major constraints in relation to implementation,

coverage of interventions and reach to priority target groups

• Gaps or areas that are not adequately addressed • Emerging issues and recommendations on

priorities for next 2-3 years

2. oRGAniSAtion of tHe iMpLeMenteRS MeetinGSThese will be 1-day meetings bringing together organi-sations that are implementing HIV and AIDS activities at district level. The organisations will include private, civil society and public institutions. It is expected that between 20 and 30 participants will attend the imple-menters meeting depending on the size of the district. 1 meeting will be organised in each province.The discus-sion during the implementers meetings will focus on all axis of the NSP. The meetings should not be confined to one axis.

3. tHe pRopoSeD pRoGRAMMe foR tHe iMpLeMenteRS MeetinGS time topic Methodology

9.00 Opening of meeting

9.00-11.30 General progress since 2005 and key achievements Group discussion and presentation

11.30 – 1.00 Constraints and areas not adequately covered Group discussion and presentation

2.00 – 3.400 Emerging issues since 2005 and recommended priorities for next 2-3 years

Group discussion and presentation

4.00 Close of meeting

nAtionAL AiDS ContRoL CoMMiSSionp.o. boX 7162AvenUe De LA pAiXKiGALiRwAnDAwww.CnLS.Gov.Rw

Final Report - UNESCO · Greenall, Mr. Tom Mogeni, Mr. James Humuza, Mr. Néhemie Nkunda Batware,...

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