The Health Resources and Services Administration (HRSA), the United States Agency for International Development (USAID) and the CDC/GAP have awarded funds to the International Training and Education Center on HIV (I-TECH) to work in the Caribbean. The goal is to expand access to treatment and prevention services for HIV/AIDS in the Caribbean region, with the CHART Network as the regional implementing partner. The program is organized along three themes: Achieving Sustainability, Enhancing Capacity, and Assuring Transfer. A midterm evaluation in 2007 showed that in general the ITECH program was reaching many of its targets. At the time of the mid-term evaluation, CHART had trained 3,828 health care workers from 26 countries throughout the Caribbean region. The CHART network has made tremendous strides in the number and types of training offered and the number of individuals trained, and I-TECH has been recognized as making invaluable contributions in terms of curriculum development, materials development, and general technical and financial support to the Network.

Following the mid-term evaluation, ITECH decided to transition greater leadership and decision making to the CHART RCU and to focus I-TECHs activities in the region on targeted assistance primarily with the RCU. The CHART RCU will begin to report to donors on behalf of the Network, and I-TECH will limit its reporting to progress on technical assistance activities with CHART. Technical Assistance to CHART has decreased over time in several key programmatic areas (e.g. training coordination and monitoring and evaluation) but remains needed in such areas as program management, fiscal and grants administration, continuous quality improvement, customization of Train Smart for human resource development planning, and pre-service curriculum development. Sustainability of the CHART Network is estimated to be reached within the next five years.

Partnership Framework: This mechanism encompasses a broad range of activities described in the Partnership Framework. Specifically the 5 strategic objectives described in the Human Resources for Health Goal Area.

Coverage: The activities under this mechanism are regional in scope. The targeted populations include: doctors, nurses, enrolled nurses/midwives, pharmacy assistants, community workers and laboratory workers.

Health System Strengthening: The key contributions of this mechanism relate to in-service and pre-service capacity development of health care workers. This mechanism contributes to the global PEPFAR goal of training 140,000 new health care workers. This mechanism supports building the capacity of CHART for long term sustainability.

Cost efficiency: CHART will become a sustainable training network that will be able to provide training and clinical mentoring to health care providers in the Caribbean. Special emphasis will be given to cost efficient strategies such as Training of Trainers, distance learning, training of community volunteers and inclusion of PLWHIV.

Monitoring and evaluation plan: The monitoring and evaluation of this mechanism includes PEPFAR indicators and a more detailed I-TECH M&E annual plan. I-TECH maintains an M&E system to capture progress towards objectives, to compare progress towards achieving goals, and to improve the quality of training and capacity building activities. A detailed M&E plan is developed each year and is reported to HRSA on a semi-annual basis. Other data collection tools have been developed and are used to monitor outputs and outcomes of capacity building. These tools are transferred to the CHART RCU.

CROSS CUTTING BUDGETS ATTRIBUTION(S)

Human Resources for Health

Key Issues:

Improve the capacity of Caribbean National and Regional Organizations to increase the availability and retention of trained health care providers capable of delivering quality HIV-related services according to national, regional and international standards.

There continues to be a strong demand for HIV-related palliative care training in the Caribbean region including an expanded focus on nutrition along with topics such as HIV and STI co-infection, disease progression, management of clinical disease, home-based care and oral manifestations. A variety of training modalities will be employed targeting physicians, nurses, pharmacists, laboratory staff, social workers, nutritionists, other ancillary health care providers and PLHIV.

While VCT training continues to be requested to support health care workers becoming VCT service providers or VCT trainers, CHART Jamaica also assisted the Ministry of Health in training health care workers on Provider Initiated Testing and Counseling (PITC). In the Bahamas, PITC workshops are conducted as precursors to Rapid Testing trainings. These trainings are held in order to prepare for the decentralization and integration of HIV/AIDS care into primary health care settings in the Bahamas.

CHART will contribute to achieving the first of the two '12s'through scaling up of prevention training for health care workers in Jamaica and the Bahamas with improved ways of measuring or estimating their impact. The CHART Training Centres in Jamaica and the Bahamas will expand their emphasis on both primary and secondary prevention training and technical assistance, and will target these trainings to a wider audience of health care workers and health care educators, including peer educators. The CHART Training Centres will be supported by the CHART RCU and I-TECH with development of Prevention-related training plans, acquisition of quality training materials and development of meaningful evaluation tools.

CHART, with technical support from the Francis J. Curry National Tuberculosis Center, will provide TB/HIV clinical consultation services to physicians in the Bahamas and Jamaica. One meeting with 20 local TB experts will be held over two days to strengthen this program. The Caribbean TB Nurse Network will meet via a quarterly conference call to discuss difficult TB/HIV cases. An in country meeting with Jamaica Ministry of Health leadership will occur in order to secure support for implementation of the revised Caribbean TB Guidelines followed by an in-country training on the guidelines. A survey will be developed to conduct a formal TB training needs assessment of HIV providers in the Bahamas and Jamaica.

CHART will provide training on treatment adherence in Jamaica and the Bahamas. I-TECH and CHART will also continue to work with local partners and the PAHO HIV/AIDS office to update the Caribbean Regional Treatment Guidelines for Adults, Adolescents and Paediatrics. Evidenced-based training plans will be used to ensure the best use of training resources in expanding, decentralizing and integrating HIV care and treatment throughout Jamaica and the Bahamas.

TB culture and drug sensitivity testing training will be provided to 30-35 participants from Jamaica and the Bahamas. Additionally, Gonococcus Drug Resistance testing will be provided to 30-35 health care workers in these countries. Additional training and/or technical assistance will be provided as identified by formal or informal needs assessments.

I-TECH will support CHART in reviewing the World Health Organization's ART core competencies and adapting them to the Caribbean Regional Treatment Guidelines so that training objectives, curriculum development and quality assurance activities are appropriately connected and support the enhancement of HIV-service delivery. CHART training materials will be reviewed to assess their compliance with agreed upon CHART Training Standards; revisions, or technical assistance for revisions, will be provided as needed. The CHART RCU will perform this inventory and assessment on a regular basis to ensure materials and training reflect current regional guidelines and meet training standards. Materials will then be made available for distribution across the Network (and to interested parties outside of the Network) in order to reduce duplication of efforts as well as to ensure consistency and quality of CHART training. The assessment of training needs throughout the region will also help to inform the development of new materials, and/or the adaptations to existing materials.

CHART Training Centres will continue to use the Stigma and Discrimination Trigger Scenarios in the majority of training activities. Additionally, people living with HIV and AIDS will continue to be included in CHART training programs as presenters. This is often an effective method of shifting the misconceptions and fear which reinforce stigma and discrimination in both the health care setting as well as in the general community.

The CHART RCU, with technical assistance from I-TECH, will continue to work in collaboration with the Caribbean Community (CARICOM) Regional Nursing Body (RNB) to support the roll out of the HIV components of the new regional curriculum for nursing students.

After participating in the outcome evaluation workshop, CHART Training Centres in Jamaica and the Bahamas will likely need further support to implement evaluation activities. The CHART RCU and I-TECH will provide support to training coordinators to create an outcome evaluation work plan, recommend and/or review evaluation tools, and assist in the interpretation of findings.

Once customizations enhancing the evaluation functions in TrainSMART have been completed the CHART RCU will work with the training centres in Jamaica and the Bahamas to implement them. Staff from each of the centres will be trained to use the new modules in TrainSMART and supported in utilizing this data in outcome evaluations.

CHART will assess faculty/tutor comfort and capacity to deliver course content and perform a targeted needs assessment for particular content areas, such as stigma and discrimination. CHART will continue the development of pre-service materials focusing on stigma and discrimination. These materials will also support patient confidentiality and use of patient-centered approaches to care.