PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
To continue strengthening PMTCT services in Region V and the border areas.
New/Continuing Activity: Continuing Activity
Continuing Activity: 18403
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
18403 11866.08 U.S. Agency for Academy for 8862 8862.08 $370,000
International Educational
Development Development
11866 11866.07 U.S. Agency for Academy for 8881 8881.07 $190,000
Table 3.3.01:
AB Prevention with out-of-school children through NGOSs.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.02:
To continue strengthening AB Prevention in MOH youth services.
Continuing Activity: 18393
18393 11871.08 U.S. Agency for Academy for 8862 8862.08 $325,000
To continue providing AB education to adults.
Continuing Activity: 18433
18433 18433.08 U.S. Agency for Academy for 8862 8862.08 $540,000
To continue implementing Life Skills Program in public and private schools.
Continuing Activity: 18394
18394 11872.08 U.S. Agency for Academy for 8862 8862.08 $100,000
Program Budget Code: 03 - HVOP Sexual Prevention: Other sexual prevention
Total Planned Funding for Program Budget Code: $714,000
Total Planned Funding for Program Budget Code: $0
Table 3.3.03:
To continue Other Prevention activities with MARPS in Region V
Continuing Activity: 18396
18396 11877.08 U.S. Agency for Academy for 8862 8862.08 $180,000
11877 11877.07 U.S. Agency for Academy for 8881 8881.07 $150,000
To continue Other Preventionin Region VII.
Continuing Activity: 18395
18395 11876.08 U.S. Agency for Academy for 8862 8862.08 $180,000
11876 11876.07 U.S. Agency for Academy for 8881 8881.07 $175,000
n/a
Continuing Activity: 18398
18398 11880.08 U.S. Agency for Academy for 8862 8862.08 $150,000
11880 11880.07 U.S. Agency for Academy for 8881 8881.07 $200,000
Table 3.3.08:
To continue providing Adult Care in Region VII
Continuing Activity: 18397
18397 11881.08 U.S. Agency for Academy for 8862 8862.08 $150,000
11881 11881.07 U.S. Agency for Academy for 8881 8881.07 $200,000
Program Budget Code: 09 - HTXS Treatment: Adult Treatment
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $200,000
Program Area Narrative:
10-PDCS Care: Pediatric Care and Support
Note: Due to delays in starting the new USG/USAID contract with AED, the transition of the USG HIV/AIDS program to the limited
geographic focus is just now taking place. During FY09 this USG concentration of support will be consolidated in Region V and
the border areas. The border areas lack the basic infrastructure necessary to support a comprehensive HIV/AIDS program, and
hence increased funding will be dedicated to infrastructure there in FY09.
Program Area Context
The 2007 National Estimates suggest that 2,719 children are living with HIV (1,328 boys and 1,391 girls). The National AIDS
Program Reporting System (DIGECITTS) states that, as of September 30, 2008, 795 children are receiving ARV treatment and an
additional 230 children are getting basic care through 27 of the 67 integrated care units (ICUs) that provide pediatric services. A
2007 PAHO/UNICEF evaluation also estimated that at least 600 of these HIV positive children will eventually require ARV
treatment. This number only reflects cumulative cases and does not include children born to mothers undiagnosed through the
PMTCT program. In 2006, 433 children died because of late diagnosis of HIV. The Clinton Foundation and USG/USAID, in
collaboration with Columbia University, have provided training to staff in six public hospitals and NGO clinics to improve the
diagnosis and treatment of children with HIV.
Weaknesses in PMTCT service provision impact children born to HIV+ mothers and the proportion of pediatric infections
identified. DNA PCR tests necessary to identify children infected with HIV have only been provided through the USAID/Clinton
Foundation Pediatric AIDS Initiative. However, USG/CDC is in the process of providing TA and equipment to the National
Reference Laboratory so that DNA PCR dry blood samples will be processed in the Dominican Republic. This will allow PEPFAR
to support laboratory capacity building and an integrated approach of PMTCT, infant diagnosis and pediatric care and treatment.
See the PMTCT and laboratory sections for additional information on this.
Recently updated PMTCT norms that establish new treatment regimens for pregnant women and their children have not yet been
put into effect in most hospitals. At present, when the PMTCT program diagnoses an HIV positive pregnant woman, treatment
prophylaxis is provided for 8-days of ARVs or Nevirapine is administered to the baby 8-12 hours after birth. A milk substitute is
offered by the GODR for the first six months of the baby's life.
Leveraging
USG interventions complement the work funded by UNICEF, the GF and other donors in pediatric care and treatment, where each
provides components necessary for the program. For example, the GF provides ARVs, rapid test kits and milk substitutes for
babies, MOH the cost of human resources, hospital infrastructure, treatment for opportunistic infections and other costs
associated with the pediatric care and treatment services, as well training and monitoring of pediatric care and treatment activities
through DIGECITSS. UNICEF supports selected hospitals' activities linking the PMTCT program to the communities through a
grant agreement with networks of persons living with HIV/AIDS (PLH). Columbia University continues to provide technical
assistance and support to a clinic in La Romana and is one of the sub-grantees of the new USG/USAID contract signed with the
Academy for Educational Development (AED). Pediatric ARVs are supplied by the Clinton Foundation and used in USG-
sponsored services.
FY09 USG Support
In FY09, USG will continue to provide technical assistance to DIGECITSS to develop model pediatric diagnosis, care, treatment
and support services to all ICUs and public hospitals as well as in NGO/FBO clinics. Through USAID support to AED and Partners
in Health (PIH), with technical assistance from Columbia University, USG will expand pediatric services to those public hospitals
and NGO/FBO clinics and community programs in selected health regions and the border area with Haiti, the focus of all USG
HIV/AIDS programs. USG/USAID and these same sub-partners will also strengthen PMTCT services in these focus areas in order
to increase the number of pregnant women who have access to quality PMTCT and thus avert pediatric infections. Model
programs implemented in the focus geographic areas will be replicated elsewhere, with support from the Global Fund, thus
demonstrating to the GODR the best practices which we hope will lead to improved policies and programs nationally. In FY09,
children and their families or care providers will also continue to be reached through the community and home-based care
services offered by the USG-supported NGOs and FBOs that provide emotional and other support, referrals for immunization and
other health services, educational assistance, nutritional support services, economic support, donated clothing and legal
assistance to obtain birth certificates, identity cards and protect inheritances. Using both FY08 and FY09 funding, USG will
continue to support cross-border work, including sharing patient information, referrals, treatment and follow-up, including services
for children. Efforts will continue to screen children born to HIV positive mothers and refer them to the pediatric AIDS services
available in 29 integrated care units (ICUs) and pediatric services on both sides of the border.
In FY09, with CDC TA support, USG/USAID/AED will design early infant diagnosis systems for collection, storage sample
transportation, diagnosis, results, and follow-up with care and treatment, as appropriate. It will also ensure that health personnel
are trained in taking droplet samples, storage, mailing, getting results and finding parents. They will also be trained to apply and
follow pediatric norms appropriately. The laboratory network being built during the year will help support this work. The results
from the USG-supported pediatric AIDS project will provide information needed to develop and implement national norms and
services to ensure children of all ages receive services.
The 2007 DHS reports that only 12% of children in the Dominican Republic are breast-fed exclusively for more than three months.
The MOH developed norms and guidelines to provide nutritional counseling and GF-provided milk substitutes for the first six
months for those mothers who will not or cannot exclusively breast feed. In FY09, USG will strengthen this intervention in Region
V and the border areas. USG also will explore opportunities for wraparound breastfeeding awareness activities with USAID's
Maternal and Child Health program.
Sustainability
GODR provides the hospital infrastructure and staff to implement the government's pediatric AIDS services. Regular pediatric
services are also included in the package of services funded under the new Social Security reform. However, ARVs and special
diagnosis tests are not provided under this program. The new Social Security program is being implemented in stages, and is
currently operating in all Health Regions (including Region V) with over 1,000,000 affiliates. However, as PMTCT norms are
modified to provide differentiated treatment, the provision of ARVs and associated tests (CD4 and viral load) remains a concern
as the costs of these services are not included in the family health insurance under the new Social Security system. USG and its
local and international partners will advocate for those to be included.
Table 3.3.10:
To provide Pediatric Care and Support.
Program Budget Code: 11 - PDTX Treatment: Pediatric Treatment
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $250,000
12-HVTB Care: TB/HIV
The Dominican Republic has one of the highest tuberculosis (TB) burdens in Latin America and is one of eight priority countries
identified by WHO/PAHO for TB control. The US Centers for Disease Control and Prevention report that in 2007 people born in
the Dominican Republic ranked 16th among patients diagnosed with TB in the United States (neighboring Haiti is 6th).
HIV prevalence among TB patients in different regions of the DR ranges from 0-20%, with a national average of 9% in 2005.
National figures show declines in HIV prevalence among TB patients although WHO has not documented this downward trend;
WHO estimated that the HIV prevalence among DR TB patients was 17% in 2004. An estimated 6.6% of TB patients in 2002 had
multi-drug-resistant (MDR) TB, one of the highest rates in Latin America. A new study on TB MDR is currently underway, and is
expected to be completed by December 2008. Results from this study will be applied to FY09 programming.
Several organizations have been working since 2001 to strengthen the National TB Program (PNCT for its Spanish name,
Programa Nacional de Control de la Tuberculosis). At that time, USAID supported three mechanisms to provide support to the
National TB Program: a direct grant to the Pan American Health Organization (PAHO); a field support grant to The Tuberculosis
Coalition for Technical Assistance (TBCTA) and later to the Tuberculosis Control Assistance Program (TBCAP); and a field
support grant to Management Sciences for Health's (MSH) Rational Pharmaceutical Management Project (RPM+) and later to its
Strengthening Pharmaceutical Systems project (SPSS). All of these contributed to improving PNCT program performance. By
2006, the PNCT achieved the global targets of 70% case detection and 85% treatment success. Another important program
success has been increasing the numbers of persons with TB who are tested for HIV. In May 2007, the sixth monitoring visit of the
PNCT was completed and recommended that: surveillance activities could be strengthened; information should be gathered and
analyzed on whether or not individual TB patients are offered and receive HIV tests; and surveillance data should be better used
to monitor and evaluate program performance.
Since 2002, TB/HIV co-infection programming has been funded exclusively by non-PEPFAR USAID child survival health
(CSH)/TB money. In FY2008 funding for TB/HIV activities was included in the FY2008 Mini-COP for the first time. Those funds
were key to enabling a more focused approach to strengthening TB treatment for co-¬infected persons. With FY2008 funds,
USAID provided support and TA to strengthen a functional patient referral system for TB/HIV co-infected patients.
As noted above, USG/USAID has provided funding and technical assistance to the National TB Program (PNCT) through grants
to PAHO and two centrally-funded projects. The PAHO grant ended September 30, 2008, though an extension of this project is
being considered in order to provide services for TB MDR patients in coordination with GF/PROFAMILIA. Due to the successes
achieved and the need to expand the worldwide STOP TB Strategy, the Dominican Republic has obtained two grants from the
Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to implement the Stop TB Strategy in 18 provinces and to support
services to treat TB MDR. Principal recipient of the GF TB grant is the NGO PROFAMILIA. USG/USAID-DR and PROFAMILIA/GF
have funded social mobilization as well through local and regional NGOs. PEPFAR support for TB/HIV program improvements
can be leveraged with these other organizations to ensure maximum impact.
In coordination with current TB partners (PAHO, TBCAP, GF, MSH/SPSS, and the MOH) and private-sector service providers,
USG/USAID will address TB/HIV priorities by providing technical assistance to the NTP program and supporting a variety of
activities, including: training personnel to follow current guidelines to report accurately and completely on HIV infection among TB
patients, TB among HIV patients, mortality and MDR and XDR TB cases in order to facilitate HIV-infected TB patient
management, HIV surveillance in TB patients, and M&E of essential program functions and outcomes; these trained personnel
will then serve as national trainers for a second tier of TB/HIV personnel in HIV counseling, testing, and referral of HIV-infected
patients to appropriate health services; strengthening TB and HIV diagnostic capacity (including the capability to perform TB
cultures and drug susceptibility testing for detecting MDR TB and XDR TB); continuing to facilitate the formation of a functional
national TB/HIV collaborative entity to oversee TB/HIV collaborative policies and activities; supporting improvement of TB/HIV
monitoring and evaluation capacity by strengthening national and local TB DOTS programs; expanding surveillance data
gathering to include information on testing for HIV among TB patients and for testing for TB among HIV patients, and by building
analytic capacity at the local and national levels; supporting (technically and financially) the establishment of a national TB/HIV
surveillance system and an updated assessment and evaluation of TB/HIV surveillance and of TB DOTS programs. USG will also
support bi-national TB/HIV activities. USG/CDC will provide support for these activities (see SI section).
Table 3.3.12:
To continue providing care and support to OVC (street children).
Continuing Activity: 18400
18400 11884.08 U.S. Agency for Academy for 8862 8862.08 $179,000
11884 11884.07 U.S. Agency for Academy for 8881 8881.07 $165,657
Table 3.3.13:
To continue providing care and support for OVC in the communities.
Continuing Activity: 18399
18399 11883.08 U.S. Agency for Academy for 8862 8862.08 $175,000
11883 11883.07 U.S. Agency for Academy for 8881 8881.07 $164,000
Program Budget Code: 14 - HVCT Prevention: Counseling and Testing
Total Planned Funding for Program Budget Code: $350,000
14- HVCT Care: Counseling and Testing
Note: Due to late release of FY07 PEPFAR funding, many planned activities have not yet taken place. In addition, delays in the
start of implementing the new USG/USAID contract with the Academy of Educational Development (AED), the transition of the
USG HIV/AIDS program to the limited geographic focus areas is just now taking place. During FY09 this USG concentration of
support will be consolidated in Region V and the border areas. The border areas lack the basic infrastructure necessary to support
a comprehensive HIV/AIDS program, and hence increased funding will be dedicated to infrastructure there in FY09. It is expected
that FY09 downstream targets will decrease from those for FY08, while upstream targets for FY09 will increase.
Program Area Context/Services
In 2002, USAID helped establish 45 counseling and testing (CT) centers in the DR. Currently there are 131 CT centers which
provided counseling and testing to 347,943 people during FY08. Of these, 76,645 were pregnant women. For the six-month
period of October 2007 to March 2008, the 79 centers supported by USG/USAID through the CONECTA project reported testing
45,599 people. Of these, 20,030 were pregnant women who received pre- and post-test counseling. Since the end of the
CONECTA project, although USG no longer provides technical or financial support to these centers, they continue functioning in
GODR and NGO hospitals and clinics. In FY09, the new USG contractor, AED, will concentrate its support on CT services in
Region V and the border areas. USG can only verify the reporting on the CT centers in which it has a role and does not have full
confidence in the reporting from other centers. These national reporting problems underline the need to reinforce information
systems and ensure full and accurate reporting. In FY09, USG will explore laboratory-based HIV case reporting and HMIS.
HIV testing is routinely performed in most health facilities, but health centers have not established a standardized laboratory
diagnosis algorithm that includes lists of authorized rapid tests to provide same-day results and quality control systems. The
existing system calls for free testing for pregnant women and a US$6 fee for others. While HIV tests are covered under the new
national health insurance plan, additional tests for HIV+ individuals are not. Many people tested do not return for test results that
require wait times as long as a month. Rapid test kits are purchased by COPRESIDA with GF money. Hospitals purchase
supplemental tests without any guidance as to which supplemental tests have been approved by MOH. In addition, test
procurement is often based on funding availability and some regions experience stock-outs. In Region V, USG/USAID-supported
laboratories improved their tracking of test kits and medical supplies, thus improving the testing services. USG/USAID supported
health personnel training to improve their capacity to offer quality counseling and testing services. Many counseling services are
overwhelmed by the number of patients and lack adequate space for confidential pre- and post-test counseling. Most CT services
associated with PMTCT provide group pre-counseling and individual counseling post-test. Health services that received USG
support in the past provide appropriate space for privacy and user-friendly quality CT. Some hospital and NGO clinic CT units
have contracted and trained PLH to provide emotional support and links to community-based support groups financed by
USG/USAID and COPRESIDA.
Leveraging/Linking
In FY09, USG will continue to collaborate with PAHO to advocate with COPRESIDA and DIGECITSS to develop policies to
validate and procure quality rapid and supplemental testing supplies to be used nationally. CDC will provide current technical
background and scientific information to inform policy and decision makers to ensure the use of quality products. In collaboration
with PAHO and UNAIDS, USG will oversee implementation of these policies once they are enacted. USG will continue to leverage
support from COPRESIDA and the MOH to strengthen CT service quality in public-sector hospitals outside the targeted regions.
We will work closely with DIGECITSS and the Provincial Health Directors in those provinces to continue providing appropriate TA
and supervision. Results of a planned gap analysis in Region V will likely support the need for USAID to continue advocating for
partners to establish new sites nationally and in Region V. USG and its local partners also will continue to advocate for the
national health insurance to cover the costs of tests needed by PLH, including CD4 and viral load that are not currently included in
that insurance.
During FY09, USG will strengthen and scale up the access to and quality of CT activities in government hospitals and NGO clinics
in the focus geographic areas, improve laboratory ability to provide test results in a timely manner, train staff in VCT, and test
model policies with the aim of getting the GODR to enact and apply similar policies. In FY09 USG will also continue to support
NGOs and PLH organizations working in the selected regions to mobilize communities to encourage preventive behaviors and
seek CT, provide post-test counseling, and facilitate active referrals for care and treatment, while also combating barriers to CT
access such as stigma and discrimination. Since March 2008, the new USG partner, AED, has been in charge of these activities,
with grants agreements signed with 14 NGOs in early FY09. Additionally, USG will continue to support trained PLH to provide
emotional support and links to community based support groups. HIV+ individuals are also referred to TB testing and, in turn and
as appropriate, to TB treatment and other services. Individuals with negative test results, either in clinics or a mobile unit, are
provided with prevention information, including contact information for prevention and other community programs.
Using FY07 funds, USG will set up two mobile CT units that will target work places, sex workers, bateyes (sugar plantations) and
migrant populations in Region V and the border areas, thus reaching people who might not otherwise have access to CT. HIV+
patrons of the mobile VCT units are referred to the nearest facility providing treatment and care. In certain communities,
particularly in bateyes in the selected regions, USG will continue to support NGOs such as ADOPLAFAM, MUDE, World Vision,
IDDI (Instituto Dominicano para el Desarrollo Integral), and new partners identified to promote CT and STI services and provide
information on service availability by distributing educational materials, promoting healthy lifestyles and encouraging testing. USG
will also continue to support routine testing and counseling via organizations that work with sex workers, such as COIN and
CEPROSH, linking these organizations to service delivery networks so they can work together in Region V and the border areas.
Street children and children and adolescents in bateyes have been identified as MARPs in the DR. With FY09 funds, USG will
continue to support NGOs that work with street children and work closely with NGOs and hospitals in Region V and the border
areas to develop and strengthen CT programs for at-risk children and adolescents. During FY09, AED will bring in a consultant to
assess the needs, current programs, and recommend actions needed to improve the HIV prevention and CT work with street
children
In FY09, USG will also strengthen laboratory systems in focus areas via an integrated system connecting laboratories, clinics and
community services to provide accurate data and improve communications among these entities with the objective of ensuring
that people return for their results, receive any care and treatment needed, and are linked with community-based services in their
communities. These systems will identify people who need to be followed up for further counseling and referrals. With FY08
funding, USG will also help strengthen labs at the national level, e.g., by helping them implement rapid testing algorithms within
the CT context, and work with PAHO and the GODR to improve policies related to CT and laboratories. See the laboratory
section for more information.
CT policy barriers mostly relate to lack of privacy and informed consent, same-day or timely delivery of laboratory results and
specialized counseling services for most vulnerable populations. At this time, all HIV testing requires affirmative "opt-in" consent.
Opt-out is illegal in the DR as per the 1993 AIDS Law. In FY09, USG will continue to work with PAHO and the GODR to address
policies at the national level so that same-day results, provider initiated and opt-out testing can be included in government
services. With MOH approval, USG will strengthen the health management information system (HMIS) and implement pilot
projects in its geographic focus areas to demonstrate the feasibility of provider-initiated testing and opt-out possibilities. We expect
that successful implementation will help the GODR change its policies and implement these changes nationally. See HSS section
for more information.
In FY09, DOD will support counseling and testing for all members of the Dominican Armed Forces (FFAA) who seek to know their
HIV status. DOD will help strengthen counseling and testing services in the FFAA's primary care units, where other services of
the new social security system of the FFAA have been incorporated. The FFAA will explore such possible settings for CT
services as stand-alone and integrated CT services within clinical settings, and mobile CT. This funding will also support minor
renovations of prospective CT centers, training staff to provide counseling and testing, and training supervisory staff to ensure
minimum quality standards for services. Linkages to care and support for HIV positive individuals will be emphasized and
strengthened.
GODR has supported CT services since their inception in 2002. In most cases, CT services are integrated into facilities offering
PMTCT services, including most public hospitals and NGO clinics in the country. MOH continues providing CT services that were
originally funded by USG. The Dominican NGOs ADOPLAFAM and PROFAMILIA continue to provide youth-friendly prevention
programs for adolescents and referral services for CT that used to receive USG funding, but require no additional support. USG
will work with the NGOs that have received small grants to improve sustainability of their programs. While HIV testing is included
in the new family health insurance plan, additional tests for HIV+ individuals are not. As the initial enrollment of poor Dominicans
increases gradually in the family health insurance, more people will have access to CT, and the related costs for those enrolled
will be covered by the new Social Security system.
Table 3.3.14:
Strengthen VCT services for vulnerable population in Region V, VII and the border areas.
Continuing Activity: 18401
18401 11888.08 U.S. Agency for Academy for 8862 8862.08 $223,425
11888 11888.07 U.S. Agency for Academy for 8881 8881.07 $245,000
To provide access to diagnostic tests (CD4) through PROFAMILIA.
Table 3.3.16:
Support to laboratories infrastructure in Region V and border areas.
Continuing Activity: 18566
18566 18566.08 U.S. Agency for Academy for 8862 8862.08 $100,000
Program Budget Code: 17 - HVSI Strategic Information
Total Planned Funding for Program Budget Code: $1,605,000
17-HVSI Strategic Information
Overview
Since the early 1990's, the DR has conducted sentinel surveillance in clinics that provide antenatal services (ANC) and treatment
for sexually transmitted infections (STI), including for both male and female sex workers, in collaboration with USG and other
donors. Multiple demographic and health surveys (DHS) and behavioral surveillance surveys (BSS) have been conducted in the
last decade, and a monitoring and evaluation (M&E) system is in place (with limited success in gathering accurate data) for the
prevention of mother-to-child transmission (PMTCT) and tuberculosis (TB) programs.
Surveys have formed the backbone of the HIV surveillance system in the DR and taken together reveal that the DR's HIV
epidemic can be regarded convincingly as driven primarily by loosely characterized subpopulations, living in specific geographic
areas, with particular socio-demographic characteristics and/or engaging in risky behavior. Mobile populations are the least well
characterized. The survey-driven HIV surveillance system in the DR, however, suffers from systemic deficiencies, not the least of
which is sustainability -- the country relies largely on donor funding to sustain the system, and the collected data are not widely
utilized for sound decision-making. Other challenges to the HIV surveillance system in the DR include deficiencies in technical and
human capacity to perform epidemiological, routine and laboratory surveillance. At the same time, low salaries impede staff
recruitment and retention and lead to poor program planning, standardization, and management.
In October 2006 CDC assessed the DR surveillance system. Based on assessment recommendations, CDC developed a two-
year work plan to be implemented in FY07 and FY08. Because PEPFAR funds were not available until late in the second quarter
of FY08, most activities will be implemented in FY09.
USG/USAID, in collaboration with GODR, conducted a DHS study in FY2007, with USG/USAID contributing about two-thirds of
the cost, while COPRESIDA, using World Bank (WB) funds, contributed the rest. USG also partially funded over-sampling in the
Bateyes (sugar plantations) in order to have more in-depth information about HIV/AIDS there. In addition, USG/USAID through
CDC contributed money to provide technical support for a BSS focused on female sex workers, drug users, and men who have
sex with men (also supported by COPRESIDA, the WB, the Global Fund (GF), SESPAS/DIGECITSS (GODR Secretariat for
primary healthcare delivery/Epidemiology unit) and other donor agencies, such as UNICEF. The USG in collaboration with
UNAIDS, UNICEF and PAHO has, for many years, also supported ante-natal clinic/sexually transmitted infection (ANC/STI)
sentinel surveillance. The 2007 change in sites from the ones that had been surveyed for more than ten years may have affected
the accuracy of results since then. In the area of TB/HIV, USG/USAID, in collaboration with PAHO/WHO, TB CAP and other
partners, has supported the development and implementation of a national strategic plan that emphasizes improving the DOTS
strategy in the DR, electronic data capture systems, and addresses MDR TB.
FY '09 USG Support
In collaboration with the GODR and other partners already supporting these types of activities, the USG/CDC Team will focus
significant resources in the coming years on supporting the development of a robust national routine surveillance system for near-
real-time collection of HIV epidemiological and monitoring and evaluation (M&E) information from routinely-provided clinical and
laboratory services and special surveys, e.g., prevention of mother-to-child transmission program (PMTCT), facilities screening for
and/or providing care and treatment services for people with HIV (including children) and/or affected by STIs, opportunistic
infections (e.g., TB, fungal infections) and other clinical conditions associated with HIV (e.g., cervical cancer and non-Burkitt's
lymphoma), and BSS. This national routine HIV-related surveillance system (which includes behavioral surveillance), will be
strengthened (irrespective of the technology currently in use) by enhancing facility capacity to record, report, analyze, and utilize
strategic information for program improvement and systematic surveillance of the index condition (e.g., PMTCT, TB, HIV
transmission-associated behaviors).
Behavioral surveillance system: The USG/CDC Team will develop a behavioral surveillance system that will address most-at-risk
and vulnerable populations (MARP)--including mobile populations (e.g., DR-Haiti border, people living in Bateyes and in tourist
areas, and working in the construction industry), ethnic populations, and those residing in Health Regions V and VII, all of which
appear to be significantly impacting the HIV epidemic in the DR at present.
Strategic information collected as a result of carefully-designed behavioral surveys and routine services provided to MARP will
serve to inform the country's HIV epidemic and "surgically" target and evaluate prevention interventions in these populations. In
this sense, it will play a role similar to the routine sentinel surveillance and M&E information system described below, but
specifically for MARP. This strategy will have an approximate five-year time horizon that will commence with establishing a
baseline framework of the MARP HIV situation in the DR. This baseline framework will be constructed through a triangulation
exercise utilizing existing behavioral and demographic data about these populations and through prospective behavioral surveys
complement the "picture." Eventually, this system should be able to inform HIV surveillance and policy primarily through routinely-
collected information about MARP. Such evidence-based policy decisions may take the form of specialized services for identified
at-risk populations (e.g., mobile health units), the establishment of facilities that increase access of MARP to services through
reduced stigma, and prevention messages tailored to specific MARP.
In FY09, the USG/CDC Team will execute a formative assessment and BSS among mobile populations in the DR with the
objectives of: describing and better understanding the context in which risk behaviors take place, including patterns of sexual
networking that contribute to high HIV prevalence and patterns associated with partnership stability and the exchange of sex for
money or other goods; identifying and describing patterns in seasonal mobility and migration in order to identify potential points of
intervention; assessing awareness and acceptability of available services, including rapid HIV testing, and to solicit
recommendations from community members and providers for improving or tailoring services; and gathering information that can
be used to rapidly develop tailored approaches for HIV prevention programs that will meet the needs of migrant men and women.
In addition to logistical, implementation and other support, the USG/CDC Team will also support the salary of an epidemiologist to
oversee the BSS, and CDC/Atlanta will provide technical assistance (TA). Such TA may also include strengthening local capacity
by sending Dominican health staff to CDC/Atlanta for advanced surveillance training.
Sentinel surveillance and M&E system: USG/CDC will also focus significant resources on supporting a routine HIV surveillance
system directed primarily at the general population and on strengthening the DR Field Epidemiology Training Program (FETP).
The information system in programs where surveillance and M&E functions have already been established (e.g., facilities that
administer the national PMTCT program and manage TB patients) will be strengthened by selecting "model" or sentinel sites (SS)
in which training, technical support and tools for best practices will be provided. This support is expected to improve and maintain
each SS's adherence with national policy and guidelines at a high level, vis-à-vis recording and reporting of clinical and
epidemiological information and promoting best clinical practices. These sites will be selected strategically in order to optimize the
USG investment by ensuring that, where possible: the SS are relatively representative of a wider population base; they are
already supported by the USG in other ways (see USG/USAID Team support below); have the capacity to effectively and
efficiently absorb the activities proposed; and can serve as centers for the training of trainers. Accordingly, these SS will serve two
principal purposes: provide reliable epidemiological and M&E information to the different hierarchical health levels of the GODR;
and provide staff and facilities for the training of trainers in order to sequentially scale up similar efforts in a greater number of
facilities. This strategy should eventually convert ALL facilities providing services for the index condition from SS to integral parts
of a national network of routine surveillance activities. Periodic sentinel surveillance surveys (e.g., ANC surveys) will be planned
every 3-5 years (more frequently at first) to calibrate the surveillance and M&E information routinely collected via this system.
To support and oversee the overall SI activities, in FY2008 USG/CDC budgeted for an in-country SI coordinator and laboratory
specialist to work closely with the GODR on the above issues. The salaries of these personnel (the positions are currently vacant)
will continue to be supported in FY2009.
In recognition of the fact that the USG Team is proposing a larger than recommended investment in SI activities for FY09, the bulk
of which is being requested by the USG/CDC Team for one specific activity (BSS in mobile populations), the following justification
is offered. After internal discussion among the various agencies, and in consultation with technical experts in SI at CDC, the
DR/PEPFAR/USG Team feels that addressing mobile populations in the DR is central to the overall USG surveillance, prevention,
and care strategy for the country. The socio-cultural and economic complexities, and therefore the vulnerability to HIV infection
and transmission of these populations remain largely uncharacterized; yet, available data show that they may be contributing
significantly to the HIV epidemic in the country. Just as important, are the practical considerations of executing the USG strategy
in the next fiscal year given that: the total funding available for FY09 mini-COP activities is limited, particularly GHAI funding; the
DR Compact concept paper has been approved and its negotiation is expected to take place in early 2009; activities programmed
for 2008 in the FY08 mini-COP have, for the most part and due to uncontrollable circumstances, not yet been executed; and
CDC's in-country agency presence was not achieved until October 2008, and the office currently has only one temporary FTE,
and has not yet hired other staff. Given all these considerations, the DR USG/PEPFAR Team strongly feels that in order to
achieve the highest public health impact consistent with the USG strategy in the DR, while wisely and responsibly using the FY09
mini-COP funding available, reliable data about mobile populations in the DR is paramount for future policy decision-making. In
addition, it is unlikely that the USG/CDC Team will have its infrastructure sufficiently developed in FY09 to execute additional
activities.
In FY09 USG/USAID will support system strengthening in strategic information in selected hospitals in focus areas of the country
prioritized by USG with two initiatives: a new MSH contract to strengthen MCH services; and technical assistance via its new
contract with AED. Both of these initiatives are designed to improve PMTCT services by integrating multiple data sources
captured at service delivery sites in order to: improve recording and reporting; help ascertain and fulfill needs in HR, training, and
medical equipment in a timely fashion; and provide data for decision-making in supply chain management, logistics, and quality
improvement.
In FY09 USG/USAID will also continue to provide technical assistance to NGOs, FBOs and CBOs to strengthen their information
systems with the aim of supporting an information system that is sustainable, responds to quality assurance tools and thus
provides reliable and accurate data. As a result, these organizations will not only have data on hand for decision making, but will
also be able to report to USG and to COPRESIDA's M&E system. In addition, the new MEASURE follow-on contract will continue
to provide technical assistance on M&E to COPRESIDA's M&E system which is currently being developed with the support of
UNAIDS and other donors.
The USG/DOD Team will support capacity building within the DR Armed Forces (FFAA) in surveillance, monitoring and evaluation
(M&E) and data analysis. A biologic surveillance study will be planned. Survey results are expected to inform the development
and implementation of improved HIV preventive interventions in the FFAA.
Finally, USG/CDC plans to strengthen the DR FETP program by performing an initial assessment of the status of the current
program and identifying weaknesses and challenges via CDC Office of Workforce Career Development. In collaboration with
local universities already engaged in academic epidemiology activities we will: 1) provide field experience opportunities for
trainees, resident and invited visiting faculty from other institutions; 2) update and develop new training materials; 3) provide
training in new and advanced laboratory techniques; and 4) liaise with other FETP programs in Latin America.
Table 3.3.17:
To strengthen information systems in Region V, VII and the border areas.
Continuing Activity: 18442
18442 18442.08 U.S. Agency for Academy for 8862 8862.08 $270,000
