Under the CDC cooperative agreement with the MOH, support will be provided for the continued strengthening of the national PMTCT program to effectively screen and prevent the transmission of HIV and provide adequate care and support. The national program is supported by other donors including the World Bank and UNICEF. The PEPFAR activities complement the support by the other donors. Provision will be made within the Cooperative Agreement to provide rapid test kits, laboratory supplies, personnel, technical guidance, quality assurance and strong links to care and treatment. Support will include support for MOH central office for data collection and utilization, supervision activities of field implementation, educational materials and programs, contract nurses for providing services at health facilities (being transferred from GHARP to MOH, see context narrative), promotion of appropriate infant feeding methods at PMTCT sites including provision of breast milk substitute when appropriate, and related training and travel. GHARP will continue to provide the core PMTCT training for MOH staff including contracted staff.

Specific Supported Activities will include:

1.) Stratify the current health sites according to the level of care to be offered in relation to PMTCT. 2.) Integrate PMTCT into the routine ANC services, and enhance the linkages between PMTCT and care and treatment. 3.) The PEPFAR technical working group will carry out a comprehensive assessment of the program. 4.) CDC/GAP will continue to provide essential supplies required for routine ANC, HIV testing and other laboratory support for the strengthening of the PMTCT program and supplies of relevant ARVs to prevent MTCT. 5.) Provide support for the MCH unit and MoH surveillance unit for data collection and utilization (including data entry staff and computers), supervision of activities at the field level and quality assurance. 6.) Nurses will be contracted to provide and supervise services at health facilities, including ensuring that there is a high level of counselling provided 7.) Provide psychological support for PMTCT counselors 8.) Optimum use of appropriate infant feeding methods will be promoted and breast milk substitutes provided where indicated. 9.) This will be supported by related training. 10.) Converting Staff (Not all positions may be rehired as the positions within the MOH may be realigned, and right-sized to fit the into the integration plan with Safe Motherhood and the more targeted approach to assigning public health nurses rather than vertical program officers). Currently, the positions to be transferred include: 14 counselors, 30 counselor/testers, 7 clerks, 11 social workers, and 5 lab aides working in regions 2,3, 4,6, and 10. Realignment will also include the increased focus being placed on labor and delivery wards as well as the more comprehensive care facilities. Staff salaries have been estimated using the MOH FY06 cooperative agreement salary scale.

The Ministry of Health's Adolscent Health Unit will continue to work with the Ministry of Education to better educate, sensitize and empower young people on the prevention of HIV infections.

Table 3.3.03: Program Planning Overview Program Area: Medical Transmission/Blood Safety Budget Code: HMBL Program Area Code: 03 Total Planned Funding for Program Area: $ 1,200,000.00

Program Area Context:

Background Blood collection and storage is currently performed at nine public and private sites in Guyana. An additional 10 sites perform blood transfusions. These sites are located in regions 2, 3, 4 (includes the capital, Georgetown), 6, and 10. (n.b.: Regions are administrative areas similar to provinces.) All of the blood collected by public sites is tested at the National Blood Transfusion Service (NBTS) laboratory in the capital or at regional laboratories. Screening for blood collected at private sites is not regulated and anecdotal reports suggest it is not always adequate. Of those units tested prior to transfusion, most are screened using only a single rapid test. Based on WHO estimates, Guyana requires approximately 15,000 units of blood per year. In 2005, voluntary, non-remunerated donors contributed approximately 30% of 4,351 units collected by the NBTS. The remaining units were collected from family/replacement or paid donors; blood supplies with a preponderance of non-paid, voluntary donors are associated with significantly lower rates of transfusion-transmitted infections (TTI). The prevalence of HIV in blood donors was 0.7% in 2005.

The national blood supply is managed by the NBTS, a sub-agency of the Ministry of Health (MOH). Legislation establishing standards and oversight has been drafted by the MOH and will be submitted to the Parliament in late 2006. In the absence of a legal foundation, a comprehensive vision for the NBTS was developed in 2006 in the form of a National Strategic Plan. This plan has been approved by the MOH and serves as the primary mission statement for the NBTS.

The NBTS has been supported by Track 1 Emergency Plan funds since 2004. A non-governmental technical assistance (TA) provider that specializes in blood safety has also been funded through Track 1 to provide expert advice and guidance to the NBTS during the period of rapid scale-up. The American Association of Blood Banks (AABB) has been the TA provider for Guyana since 2004; however, AABB will disengage from Guyana at the end of FY06. The decision to cease work in Guyana was based on AABB's desire to focus its international activities exclusively in Africa where it is a Track 1 blood safety grantee in five countries. The MOH will select a new Track 1 TA provider in early 2007 through a review of the orginal applications from the other 4 designated Track 1 blood safety TA providers. The new TA provider will be encouraged to establish an in-country presence to carry out its activities.

In past years the NBTS has received up to $1 million in Track 1 funds. The funding request for FY2007 ($400,000) reflects a need to allow the NBTS to spend down significant carry-over funds from FY05 and FY06 and the shifting of funds to SCMS for commodities management for NBTS laboratory activities.

Summary Despite two and a half years of Track 1 funding and TA support, the NBTS remains a work in progress. At current collection and screening levels, the NBTS provides less than a third of the national need for blood and blood products. This shortfall is responsible for the frequent cancellation of surgeries in public hospitals, as well as increased mortality in acute care cases (e.g., complications in childbirth). A number of structural factors contribute to the problem, including:

1. A weak procurement and logistics system that contributes to periodic stock outs of key reagents and supplies. 2. A lack of human resource capacity at regional transfusion centers and blood banks to ensure quality blood screening. 3. Incomplete or unavailable standard operating procedures for staff engaged in blood collection, screening, storage and distribution. 4. A lack of coordinated training in the appropriate use of blood for physicians. 5. Insufficient programmatic activities to promote blood donation and recruit blood donors. 6. A lack of administrative capacity to ensure grant funds are spent efficiently and appropriately. 7. Weak data management systems contribute to high rates of wasted blood due to an absence of

adequate tracking mechanisms.

In addition to these structural problems, the blood service is also hampered by a significant systemic barrier, namely the presence of multiple hospital-based blood banks that are not linked to or coordinated by the central NBTS. Through the NBTS, the MOH has used Emergency Plan funds to develop the regulatory mechanisms (and legislation) to centralize operational responsibility for the national blood supply within the NBTS.

Objectives In FY07, Emergency Plan funds will be used to address the structural and systemic barriers identified above. Primary objectives for FY07 include:

1. Reducing the incidence of stock-outs and other supply shortages. This will be accomplished by engaging the services of the Supply Chain Management Consortium (SCMC) to streamline procurements and facilitate logistics through the SCMC-supported warehouse in Georgetown. 2. Improving the level of technical competence among laboratory workers in the Georgetown lab as well as in the regional laboratories. The Track 1 TA provider will provide the necessary instructors, curricula and materials. CDC will support the NBTS to complete the baseline SOPs required to launch these training activities. 3. Reducing unnecessary orders for blood transfusion by increasing physicians' access to high-level training on the appropriate use of blood. This training will be provided by the Track 1 TA provider and CDC. 4. Strengthening the NTSC's ability to educate, recruit and retain voluntary, non-remunerated blood donors. 5. Ensuring adequate training and mentoring for the NTSC's new program administrator. 6. Supporting the NBTS to strengthen its data management system with appropriate technologies.

In addition to Emergency Plan funds, the NBTS and its USG partners will work to identify other sources of funding and technical support for blood safety. The World Health Organization's regional program for the Americas (PAHO), the World Bank, and the Global Fund are all active in Guyana and will be contacted about new partnerships and linkages to other program areas/funding sources.

In addition to the required PEPFAR indicators, country level indicators will include: 1) Improvement in adequacy of blood supply (quantity and access), 2) Increase in voluntary donors as a proportion of all donors (blood quality), 3) Passage of blood safety legislation to standardized transfusion services 5)Absorption rate (percent of allocated funds dispensed in year of award).

In Country Targets Adequacy of Blood Supply # units collected: 8,000 Requests for blood satisfied: 90%

Quality of Blood % of voluntary donors: 50% % blood used for transfusion screened for TTI : 100%

Sustainability of Program Passage of legislation establishing standards for transfusion services

Program progress % of allocated funds allocated dispersed in year of award: 90%

Decrease in number of private blood banks: 7

Working system of cost-recovery for providing blood to private hospitals

Program Area Target: Number of service outlets carrying out blood safety activities 10 Number of individuals trained in blood safety 60

Table 3.3.03:

Through a cooperative agreement the CDC will continue to provide core support to the MOH for TB and TB/HIV program activities, with the purpose of building MOH's TB/HIV expertise and helping alleviate some of the TB/HIV diagnostic challenges that persist in-country. This funding will provide funding support for two contract clinical staff and one contract laboratory staff and will provide laboratory support. CDC will work closely with MOH and Global Fund to identify long-term funding sources for these staff to ensure sustainability of adequate staff to provide care for TB/HIV co-infected patients.

In FY07, staff trained in HIV counseling and testing will transition from Family Health International (FHI) to positions directly supported by the MOH. Funding will be from CDC through its existing cooperative agreement with the MOH. This transition shifts both technical and administrative oversight for these health professionals to the Government of Guyana. USG will continue to provide technical assistance through existing programs to ensure a seamless transition and continued enhancement of service delivery. As these counselor-testers will continue to utilize GHARP reporting tools, targets are included under those for Activity #8004 for FY07.

CDC will provide ongoing support to infrastructure development activities for the Ministry of Health (MOH) as it expands its care and treatment program. Late in FY06, CDC provided $100,000 to support the physical establishment of a dedicated 30-bed infectious disease hospital ward at Georgetown Public Hospital (GPHC). Minor renovations will be completed late in 2006, and FY07 funding will focus on systems support, including maintenance of the ward and special expenses.

GPHC is actively recruiting the services of an infectious disease specialist to serve as the hospital-based director of the ward. As there are no infectious disease-trained physicians in Guyana, the director will likely be from the greater region or a Guyanese physician from the diaspora. Recruitment activities will occur locally and regionally and include advertising the position in Guyanese and Caribbean newspapers, international health journals, through PAHO offices, and on Guyanese news websites which are widely read by the diaspora. Engaging a physician from the region will help establish links to regional practitioners and to the diaspora; each of these communities are potential sources of healthcare personnel who could alleviate some of the human resource shortages in Guyana's healthcare system.

Under the CDC cooperative agreement with the MOH, CDC will support the continued improvement of quality of care and treatment on the infectious disease ward. This ward will be the focal point for the institutionalization of treatment protocols and training of medical and other professional staff in proper patient care and management of AIDS and related infectious diseases. Supported activities will include: services of an infectious disease physician; training support for physicians, medical students, nurses, counselors, and other ward staff; support for monitoring and evaluation activities; and the purchase of essential supplies for the management of the ward. MOH will capitalize on connections to the diaspora through twinning with Guyanese physicians at universities and hospitals abroad, allowing for an exchange of clinicians and experiences. Education of staff and adherence to best practices for infection control will produce a model unit with a positive image that diminishes health worker prejudices regarding caring for HIV-positive patients. Through a provider-initiated opt-out testing policy on the ward, new patients will be diagnosed and channeled into treatment. Having a designated ward that is adequately staffed and equipped will encourage patients to seek hospital treatment when needed, which will lead to a reduction in HIV/AIDS-related mortality. The physician director will liaise with FXB and the MOH outpatient treatment system to ensure linkages to care upon discharge and referral to appropriate community support services.

Over the last two years, MOH has implemented HIV rapid testing on labor and delivery wards, PMTCT and VCT sites, provided infrastructural support for CD4 testing, provided technical and policy support for the establishment of the NPHRL, and in collaboration with the EU project has strengthen the laboratory Quality Assurance (QA) program. MOH has expanded services by contracting two laboratory staff, a phlebotomist and laboratory aid, through funds from the cooperative agreement with CDC. In FY07 MOH will design and implement a virtual NPHRL during construction, with support from FXB and CDC, to ensure that there are clear plans for staffing and maintenance of the lab in the coming years. MOH will develop a transition plan to assume management of the CD4 testing system and will review and approve all testing protocols related to the treatment program. CDC will expand its current system of funding 25% of required reagents at Georgetown Hospital and provide this benefit to the two expanded treatment sites as well. These activities will transition to SCMS during FY07. MOH will design a protocol for pediatric testing that will include a system for shipping of specimens to an external reference lab until DNA PCR technology is available in Guyana.

Through Atlanta and country-based technical assistance and financial assistance through a cooperative agreement, CDC will work to improve the MOH capacity for internal SI and M&E. A portion of the funds from the 2006-2007 cooperative agreement has been obligated to provide contract staff, equipment, travel, supplies and contractual services.