2008 PEPFAR Country Profile Update: Rwanda
Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.
(The following document is a 2008 update to the status of PEPFAR funding and related issues in Rwanda. Click Here to Read Rwanda's 2005 Original Country Profile)
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and, to a lesser extent, to over one hundred other countries. PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV/AIDS and demonstrated the political will to put that concern into action. At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying. Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20% of the funds could be spent on prevention efforts. Moreover, 33% of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs. Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, which they believed to be inconsistent with their religious teachings.
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time.
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds.
In addition to this data, each update also offers further analysis on particular items of note in the country. And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries. While these updates can be read independently of the original profiles, reading them together affords an even richer perspective.
Rwanda’s first AIDS case was reported in 1983. Since then, the AIDS epidemic has expanded to affect all segments of society. While Rwanda’s HIV prevalence of 3 percent is relatively low compared to that of other PEPFAR focus countries, and Africa more generally, the HIV/AIDS epidemic continues to have a devastating impact on the welfare of Rwandans. The epidemic, coupled with ongoing civil strife has transformed the Rwandan population into one that is relatively young. In fact almost half (42.1 percent) of its citizens are under the age of 15 and less than 3 percent are 65 or older. The healthcare worker shortage compounds the crisis, with only one doctor for every 50,000 people and one nurse for every 3,900 people.
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Rwanda. The stories behind the statistics are fleshed out in greater detail following the chart.
A PORTRAIT OF RWANDA IN NUMBERS
The most recent data on HIV prevalence within the adult population is from the 2005 Rwanda Demographic and Health Survey (RDHS) which estimates the HIV prevalence to be 3 percent. Prevalence varies dramatically by region and by sex. For example, 7.3 percent of the population in urban areas is HIV positive compared to just 2.2 percent in rural areas. Similarly, 2.3 percent of men are HIV positive compared to 3.6 percent of women. Data from 2007 estimates the number of people in Rwanda currently living with HIV to be 150,347.
The Rwandan genocide of 1994 and conflicts that took place from 1996 to 2000 have devastated the country, exacerbating the HIV/AIDS epidemic. During these periods of conflict there was increased sexual violence and assaults against women, facilitating the transmission of HIV to an overwhelming number of women. During the period of genocide more men than women were killed. As a result, women currently make up roughly 70 percent of the population and head over 38 percent of households. Another lasting impact of the 1994 genocide is that many people in Rwanda have become increasingly mobile, returning from refugee camps or moving to more densely populated urban areas. Increased mobility is often associated with increased risk of transmission of HIV. The most common modes of HIV transmission in Rwanda are through heterosexual contact (forced and consensual) and mother-to-child transmission.
The government of Rwanda has made it a priority to prevent the spread of the epidemic. A National AIDS Control Program has been established and there are currently several policies in place to deal with the epidemic. For example, the government has implemented several strategies including a National Plan of HIV Prevention for 2005–2009, an HIV/AIDS Treatment and Care Plan, National Policies on HIV/AIDS for the education and professional sectors as well as one for orphaned and vulnerable children (OVC), and a National Condom Policy. This multi-sectoral approach is carried out by the National AIDS Control Commission (CNLS), which was created in 2001.
In Rwanda 67 percent of the population is under the age of 24. In an effort to respond to this heavily weighted demographic, the current plan for Rwanda places specific emphasis on youth and behavior change. There have already been some positive strides made in this area. For example, according to a 2008 country progress report on HIV/AIDS, roughly half the youth population has good knowledge about modes of HIV transmission and how to prevent transmission from occurring.
The government has made additional efforts to create an open dialogue involving political, religious, and cultural leaders. Anti-AIDS clubs have been created in elementary schools, and first grade teachers have received guides for civic education which include a module on HIV/AIDS. Rwanda also promotes an “EABC” message: Education, Abstinence, Be Faithful and Condom Use.
In 2005, Rwanda’s national AIDS campaign message was, “individual responsibility to break the chain of transmission.” Voluntary counseling and testing centers (VCT) have been promoted, not only as a way to access drugs, but also a means of taking personal responsibility. In the most recent Rwanda Demographic and Health Survey, 97 percent of the women and 95 percent of the men surveyed agreed to give blood samples. This willingness to accept treatment and care shows that some of the efforts to decrease the stigma associated with the disease have been successful.
UNGASS also reports that Rwanda has made steady progress in treating, caring, and supporting people living with HIV/AIDS (PLWHA). The number of antiretroviral therapy (ART) sites has steadily increased, and in December 2005 approximately half of those in need of ART treatment were receiving it. The government also released a Ministerial Decree in 2004 which allowed for affordable access to ART to poor people, based on a sliding scale of family wealth.
However, in spite of its successes, the government still faces many issues. Stigma, while less common than in previous years, still exists among people in higher socio-economic brackets. Also, condom usage is still low when compared with the rate of sexual activity. Results of a 2005 condom accessibility study by Population Services International (PSI) show that 80 percent of Rwandans have seen, heard about, and know that condoms are an effective barrier method to HIV. However, many Rwandans still associate condoms with promiscuity which makes it difficult for young people and married couples to negotiate condom use for HIV protection or as a family planning method. The government is working to change this, with a National Policy on Condoms that combats discrimination and stigma.
President’s Emergency Plan for AIDS Relief (PEPFAR)
PEPFAR has implemented HIV programs since 2004. Since this time, PEPFAR has allocated over $300 million to Rwanda. The initial grant was for $39,300,461. Funding has increased substantially over the past four years, with over $100 million allocated in 2008. For its small size and relatively low prevalence rate, the country receives a large portion of PEPFAR funds compared to its neighbor recipients like Ethiopia, Kenya, and Tanzania.
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
Allocated PEPFAR Funds 2004–2008*
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.
** Total funding allocated to Field Programs only, excludes Agency costs.
Treatment programs have traditionally received the bulk of PEPFAR funding in Rwanda; they accounted for nearly half of the total allocated budget in 2008. Care programs follow, receiving just over one-third of funding. Prevention programs receive the least amount of funding. Between 2005–2006, they decreased by $1,648,809 and currently make up 23 percent of the overall 2008 budget. In addition, prevention funds have received the smallest increases in funding; whereas allocations for care programs have tripled and funds for treatment programs have more than doubled since 2004, funds for prevention are still less than double what they were in 2004.
AB funding consistently receives the largest share of prevention funds in Rwanda, with over 34 percent of the prevention budget going to AB-only programs. AB programs have received an increase in funding each year under PEPFAR, while overall prevention funds experienced a decrease of over $2 million between 2005 and 2006. In 2008, OP programming received an increase of over one million bringing it to17 percent of the total prevention funds and about 4 percent of funding overall.
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding.
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP). The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR’s overall impact on prevention programming in the country.
For instance, Catholic Relief Services (CRS) received $176,592 for AB-only programs in 2007 in Rwanda. However, it is not known how much of this money was used to support CRS’s AB-only curriculum “Choose Life,” which was used in school education programs and marital counseling, and how much was used to strengthen, “referrals to health facilities for VCT and other HIV/AIDS services.”
According to the 2007 Country Operational Plan, there were three AB-only programs, twelve AB/OP programs, and one OP-only program for Rwanda. Of the thirteen OP programs funded in 2007, only five promoted the correct and consistent use of condoms in their HIV-prevention efforts. These programs focused on military members, substance abuse clinics, and sero-discordant couples (couples in which one partner is HIV-positive and the other partner is HIV-negative). Glaringly absent, however, were other groups such as men who have sex with men (MSM) or sex workers. Although we know that at least one million condoms were designated to be distributed to various condom outlets in Rwanda by these OP programs, the details on how many were actually distributed and how this distribution was carried out is not reported by the OP programs. However, it is known that Rwanda’s Ministry of Health distributed 833,863 male condoms and 2,441 female condoms in 2006.
The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for Rwanda. This list indicates whether grantees received only Abstinence-only/Be faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.
Organizations that received only AB funding:
Organizations that received both AB and OP funding:
Organizations that received only OP funding:
The top AB-only provider, Catholic Relief Services, which as mentioned earlier received $176,592 in grants, had as its goal reaching 16,535 people through community outreach. Its program, “Avoiding Risk, Affirming Life” is an AB-only program delivered to nurses, social workers, community volunteers, youth, and people living with HIV/AIDS (PLWHA) in parishes and clinics all over the country. The program teaches HIV prevention through abstinence, secondary abstinence (remaining abstinent after having been sexually active), and fidelity. The AB messages are tailored to patients based on their age, marital status, HIV status, and identified risk behaviors.
The top AB/OP provider is Community Habitat Finance (CHF) International, which received $350,000 for OP programs and $750,000 for AB programs. CHF works in collaboration with the Community HIV/AIDS Mobilization Program (CHAMP) to “change high-risk behaviors and norms and to effectively promote abstinence before marriage and fidelity in marriage.” CHF and CHAMP promote correct and consistent condom use in their OP funded efforts that targets 30,000 people and deliver AB messages that target 105,000 people.
John Snow, Inc. was the one provider receiving only OP funds which totaled $100,000. John Snow’s uses its OP funds to conduct research on the availability and accessibility of condoms by tracking usage among HIV-positive people and focuses on increased condom availability in places that ordinarily do not distribute condoms like at military, refugee, and transit camps.
Items of Note: Refugees and the AIDS Epidemic
In 1994, approximately 800,000 people were killed during the period of civil war and genocide in Rwanda. Millions of people crossed the border into neighboring countries, such as Tanzania and the Democratic Republic of Congo. Most have since returned to face high rates of poverty and a recovering political infrastructure. Today, Rwanda has over 50,000 refugees.
There is a common misconception that refugees are responsible for introducing disease to the area to which they relocate which increases stigma against them. The reality is that refugees fleeing from all over the country come from areas that have vastly different prevalence of HIV, as well as travel to areas with varying prevalence of HIV, and are not more likely than any other group to transmit HIV.
However, refugees, women and children in particular are in a vulnerable position. They are often coerced into having sex or raped, and they are more likely to voluntarily engage in sexual behavior that places them at an increased risk of contracting HIV such as transactional sex for food or money. They usually lack a safe blood supply and access to healthcare and condoms.
Central to the complexity of addressing the underserved needs of refugees is the absence of a single international organization devoted to addressing their protection and assistance. Relief workers dealing with unfolding disasters and limited resources often feel that HIV/AIDS related needs often take a back seat to other matters. This sentiment can be compounded by the fact that symptoms related to HIV/AIDS may not manifest until years later.
The governments of neighboring countries where Rwandans have relocated often fail to allocate funding to address refugees needs. Refugees are excluded from multi-million dollar HIV/AIDS programs that are available to citizens of the country. UNAIDS, which is the main agency of the United Nations committed to the prevention of HIV, recognizes that countries hosting refugees need to be reassured by the international community that they will not forego assisting the host country’s own needs when giving aid to refugee populations. PEPFAR has also made efforts at combating this issue by urging local governments and organizations to address the needs of refugees. Moreover, PEPFAR aims to implement its programs in a way that does not discriminate against refugees’ ability to access to prevention, treatment, and care services.
It is imperative that host governments and other agencies, including PEPFAR, continue to work to ensure that refugees are reached effectively by HIV prevention, treatment, and care programs.
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
1. Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion. As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
2. Increase Transparency of PEPFAR Prevention Funds
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement, OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession.
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.
4. Rescind the Anti-Prostitution Pledge
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable. The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease. However, such segmentation has also led to too narrow a framework/conceptualization. Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground.
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
6. On-the-Ground Monitoring of Funded Activities
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways. Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming. PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs. We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 Ibid., 5
† According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
 Ibid., 5
 Ibid., 215
 Ibid., 217
 Ibid., 307
 Ibid., 313
 Monitoring ICPD Goals – Selected Indicators, 94
 Monitoring ICPD Goals – Selected Indicators, 94
 World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 15 July 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 13
 2008 Report on the Global AIDS Epidemic Annex 2, 296
 Ibid, 292
 United Nations General Assembly Special Session on HIV/AIDS Country Report, 12
 Ibid., 36
 Ibid., 42
 Ibid., 37
 Rwanda FY 2007 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 22 July 2008, http://www.pepfar.gov/documents/organization/103939.pdf 114
 Ibid., 153, 174, 183, 186, 194
 Ibid., 183
 United Nations General Assembly Special Session on HIV/AIDS Country Report, 28
 Rwanda FY 2007 Country Operational Plan
 Ibid., 117
 Ibid., 174
 The President’s Emergency Plan for AIDS Relief Report on Refugees and Internally Displaced Persons, February 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 22 July 2008, http://www.state.gov/documents/organization/63694.pdf 6
 Ibid., 4–5
 Ibid., 8