Since 2004, as a CDC Global AIDS Program implementing partner for HIV care and treatment in Guyana, FXB has supported the US government PEPFAR goals in Guyana. To address PEPFAR care and treatment goals, FXB works with US government partners and the Guyana Ministry of Health (MOH) to expand and strengthen the delivery of PMTCT, VCT, adult and pediatric care and support, adult and pediatric treatment, TB and TB/HIV care and treatment, and laboratory infrastructure, in Regions 2, 3, 4, 5, 6, and10 of Guyana.

FXB will continue to implement a transition plan for long-term sustainability of human resource capacity that includes building local physician and nursing capacity and integration of HIV clinics with general medical clinics to maximize the use of available human resources. While human resources support for the provision of comprehensive HIV care (PMTCT, VCT adult and pediatric care and support, adult and pediatric treatment, TB and TB/HIV care and treatment, and laboratory infrastructure) will continue, FXB-sponsored staff are expected to transition to the MoH as early as September 1, 2010, but no later than January 31, 2011. Continued support for improvement of quality of care nationally will be provided through physician-targeted clinical audits and feedback; and overall assessments of the quality of the continuum of HIV, TB and TB/HIV care will continue through the national HEALTHQUAL CQI program. Leadership and expert consultation to the Guyana HIV care and treatment program and other partners on HIV-related policies and protocols will continue through committee and TWG memberships. In addition, FXB will continue to provide expertise to the national TB program to diagnose, treat and manage patients co-infected with HIV and TB. FXB will continue to support capacity to screen, diagnose and treat co-infected patients, while building capacity to manage TB-HIV co-infection through clinical mentoring and training. FXB will also continue to provide leadership, support and expert consultation on clinical and laboratory policies and protocols in this area. In relation to laboratory infrastructure, FXB will deliver technical assistance for building regional laboratory capacity to support HIV care and treatment, quality assurance monitoring, training; development and/or revision and implementation of laboratory testing protocols, and active participation in committees and TWGs.

Crosscutting attributions that will be addressed by FXB include health systems strengthening; food and nutrition: policy, tools and service delivery; and gender reducing violence and coercion.

Health Systems Strengthening (human resources for health, in-service training, and task shifting): FXB's capacity building to support the national care and treatment program through a 1-year clinical mentoring program for in-service physicians has yielded 6 graduates to-date; there are currently 7 in-service and 16 pre-service physicians enrolled in the program, and an additional 65 new in-service physicians are expected to enroll in a modified version of the program in late FY'09. FXB will also explore the possibility of developing and piloting a pre-service training program to address the urgent need for case managers to coordinate medical and psychosocial care needs of patients. FXB will continue to facilitate in-service training through development and execution of facility specific annual training plans, responding to requests from the National AIDS Programme, and offering opportunities for local clinicians to gain continuing education credits for re-licensure/registration with the local regulatory bodies (Guyana Medial, Nursing, Dental and pharmacy Councils), FXB will also facilitate training and mentoring to support task shifting ART provision to the medex cadre of HCWs in areas with no or limited physician coverage, i.e., hinterland areas.

Food and Nutrition: Policy, Tools and Service Delivery (nutritional assessment and counseling): FXB will provide nutritional assessments and counseling as part of the minimum package of care and support services offered to HIV-infected adults, children and pregnant women.

Gender: Reducing Violence and Coercion (strengthening rape care services, including the provision of HIV PEP): FXB will continue to support the emergency and follow up care and counseling for victims of sexual assault, including the provision of HIV PEP and related clinical and laboratory monitoring at the 16 Ministry of Health ART sites supported by FXB; and will support the introduction of PEP at selected hospital emergency departments.

Key issues that will be addressed by FXB include family planning and TB.

Family Planning: As part of the reproductive healthcare package offered by the MCH department, FXB will continue to promote and provide family planning counseling including safer sex and pregnancy prevention options.

TB: FXB will continue to provide expertise to the national TB program to decentralize screening, diagnosis, and treatment of TB and TB/HIV infected patients to designated primary health care facilities that offer HIV care and treatment services. Screening will be decentralized through ongoing coordination of PPD training for several cadres of HCWs (nurses, DOT workers, VCT providers). Treatment will be decentralized by expanding the supply chain to provide prophylactic and treatment drugs to designated primary care facilities. Additionally, TB and TB/HIV M&E systems will be expanded to designated primary care facilities to ensure required data collection and accountability for drug supply management. Laboratory capacity to conduct microscopy and will be strengthened through quality assurance monitoring and training; capacity for drug sensitivity testing will be outsourced in the interim of the Ministry of Health's planning to develop local capacity for same.

FXB's M&E plans for its clinical activities are integrated with the Ministry of Health's national patient monitoring system and HEALTHQUAL CQI program. In addition, annual targets are set in collaboration with the PEPFARGuyana Strategic Information technical lead. FXB reports on its programmatic progress through semi-annual, interim and annual reports to CDC and PEPFAR-Guyana Strategic Information technical lead; and financial expenditures are reported through submission of quarterly and annual financial status reports to CDC.

In FY'2010 FXB will continue to serve as the Ministry of Health's primary partner in the delivery of the standard package of HIV clinical care and support services to HIV infected and HIV-exposed and affected males, females, adolescents and their families. In FY'09 FXB led the revision of the National Guidelines for Management of HIV-Infected and HIV-Exposed Adults and Children and protocols for viral load and HIV drug resistance testing. In FY'2010 FXB will continue to provide expert evidenced-based guidance for the revision and/or development of other clinical guidelines and protocols as needed.

Adult care and support services will be provided at 19 of the current 20 Ministry of Health sites that offer HIV care, treatment and support services across Regions 2, 3, 4, 5, 6, and 10. Currently there are no plans to scale up additional sites. Thus in consultation with the MoH and in keeping with the overall PEPFAR strategy, FXB plans to commence integrating HIV clinics with the existing primary care (general medical) clinics at the same sites. This activity will include the training of medical interns, new and existing resident physicians and other cadres of HCWs, as well as the engagement of HIV-trained HCWs, in order to sustain the delivery of HIV care and support services.

The FY'09 planned initiation of a staggered transition of human resources to the MoH was postponed after the MoH indicated that they could not absorb the targeted positions until September 2010. FXB will continue to work closely with the MoH to implement and monitor the transition in a timely manner.

Through human resource support (physicians, nurses, community outreach workers) and training, FXB will continue to support facility-based inpatient and outpatient adult HIV care and support services as part of a continuum of primary health care, including: clinical monitoring and management of OIs (cotrimoxazole prophylaxis, laboratory testing) and other HIV-related complications and co-morbidities; TB screening; nutritional assessment and counseling; assessment and management of pain; supportive supervision and co-facilitation of facility-based PLHIV peer support groups and referrals to community-based PLHIV peer support groups; referral to social support and HBC services, as well as end-of-life care at the country's only hospice facility, St. Vincent's Depaul Centre; contact tracing and VCT to identify and test HIV-exposed adults and children; and monitoring patient retention through adherence assessment and counseling including facilitated disclosure, and patient defaulter tracking. FXB will continue to support prevention services for this population by developing a minimum package of prevention services including prevention for positives counseling. FXB will also explore the possibility of implementing a nutritional support program for clinically malnourished HIV-infected patientsalthough there are existing local food support programs, the food provided does not meet the definition of therapeutic, micronutrient or supplemental food.

FXB will work collaboratively with MoH social workers to coordinate patient care with other inpatient, outpatient and community-based care and support providers through telephone and personal contact, as well as bi-directional referral forms. FXB will explore collaborating with the National AIDS Programme and an FBO and/or HIV workplace program to develop and pilot a sustainable model for providing community-based support at these facilities. FXB will also explore the possibility of developing and piloting a pre-service training program to address the urgent need for social support case managersthese case managers would work under the guidance of a qualified social worker to develop, implement and monitor a case management plan that identifies and addresses the individual patient and family social, medical and economic needs.

Quality of adult care and support services will continue to be assessed semi-annually through the national HEALTHQUAL (CQI) program. FXB will intensify peer review and feedback on physician charting to ensure that adult care and support services are consistently delivered in accordance with national guidelines. Additional program data drawn from the national patient monitoring system will be reviewed and discussed at the national care and treatment steering committee meetings, with recommendations to modify interventions accordingly.

Adult treatment services are targeted to HIV infected males, females and adolescents accessing care at 16 of the current 17 Ministry of Health sites that offer HIV treatment services across Regions 2, 3, 4, 5, 6, and 10. Services include clinical and psychosocial assessment of ART readiness, laboratory monitoring and adherence monitoring and support.

FXB's plan for long-term sustainability of ART delivery emphasizes activities that build capacity in the local physician community. In FY'2010, these activities will continue to include utilize innovative and creative approaches to address the human-resource shortages that threaten the advancement and sustainability of the Guyanese treatment program. Such strategies include contracting with physicians to provide complete clinical coverage for all treatment sites and task shifting ART provision to the medex cadre of HCWs in the hinterland areas. In the interest of developing local capacity and long-term sustainability for the program, effort will be focused on the continuation of clinical mentoring of local clinicians to provide HIV care and the integration of such mentoring into the training programs for pre-service physicians (medical interns and students) from the Guyana-Cuba training partnership as well as the University of Guyana medical training program. FXB will provide physician mentoring and consultative oversight to in-service and pre-service HCWs serving on the Georgetown Public Hospital Infectious Diseases and regional hospital inpatient wards. FXB will also continue to engage and support local physicians who have completed the formal clinical mentoring program to sustain the development or revision and delivery of standardized curricula on basic HIV care for several other cadres of HCWs including medical students, pharmacists, medex, nurses and physicians.

Quality of adult treatment services will continue to be assessed semi-annually through the national HEALTHQUAL (CQI) program. FXB will also intensify peer review and feedback on physician charting to ensure that adult treatment services are consistently delivered in accordance with national guidelines. Additional program data drawn from the national patient monitoring system will be reviewed and discussed at the national care and treatment steering committee meetings, with recommendation to modify interventions accordingly.

The current overall level of adherence is estimated at 70% - 80% but is thought to be on the decline based on patient reports. Adherence monitoring will be intensified to entail an adherence assessment at every clinic visit (including pill counts), group and individual adherence counseling pre/post ART initiation, referral to community-based socio-economic support services, and nutritional assessment and counseling. FXB will also undertake a 9-month public health evaluation: Assessing the Concordance of Antiretroviral (ARV) Adherence Measurement Methods and Determining the Best Predictors of ARV Adherence in Guyana.

In FY'09 FXB fully transitioned its staff and activities related to the operation of the CD4 suite at the NPHRL, to the MoH. Therefore, in FY'2010 FXB's role (through our Laboratory Advisor) will revolve around the delivery of technical assistance for building regional laboratory capacity to support HIV care and treatment; quality assurance monitoring; training; development and/or revision and implementation of laboratory testing protocols; and active participation in committees and TWGs.

FXB will work collaboratively with the NPHRL and Regional Health Services to strengthen regional laboratory capacity through quality assurance (QA) implementation and monitoring for general and specific (CD4 and HIV rapid testing) laboratory functions and assays; and delivering CD4 training/retraining to regional hospital laboratory personnel. FXB will also continue to collaborate with PAHO and the National Blood Transfusion Services (NBTS) to provide oversight and monitoring for safe blood donation, screening, storage and dispensing including training and implementation of the revised QA manual completed in FY'09.

In collaboration with the VCT unit at the National AIDS Programme, FXB will provide ongoing training/retraining on HIV rapid testing. FXB also plans to build sustainable local capacity to address HIV rapid test training needs through facilitation of VCT trainer of trainers training.

FXB will also continue to work collaboratively with the MoH, CDC and PAHO to continue to refine and implement the national strategic plan for laboratories, through the provision of technical assistance for the introduction of laboratory assays to support diagnosis and clinical management of HIV infection in infants (HIV DNA PCR) and adults (HIV RNA PCR), opportunistic and sexually transmitted infections (smear microscopy), and resistance to HIV and/or TB drugs. This will entail the development of protocols, validation processes and/or correlation studies, SOPs, and training packages for each such laboratory assay.

In FY'2010, FXB will continue to provide evidenced-based technical assistance, human resource support, clinical mentoring and training, and leadership and management coaching to the staff of the National TB Control Programme (based at the Georgetown Chest Clinic),

FXB will continue to expand TB screening for HIV-infected patients with emphasis on vulnerable populations at key primary, secondary and tertiary service outlets (high volume PMTCT sites, inpatient wards, prisons; and integration of TB screening into the HIV care and support and treatment programthrough training of several cadres of HCWs at these service outlets, and aggressively strengthening the screening and referral linkages between PMTCT sites, inpatient and outpatient HIV care and treatment sites (Infectious Disease Ward at GPHC, regional hospital wards and clinic), and regional and Georgetown Chest Clinics. Continued expansion of screening for HIV infection among patients with TB, will be accomplished through continued assignment of 1-2 full-time HIV counselor/testers to the inpatient (infectious diseases, medial, pediatric) wards at GPHC, and to support medical outreach to local prisons.

FXB will continue to build the Georgetown Chest Clinic (Region 4) as the primary national referral, consultation, and treatment site for the management of TB and TB/HIV co-infection by providing: comprehensive high quality multidisciplinary clinical care and monitoring including: collection, follow up and delivery of results for sputum for miscroscopy/culturing/sensitivity; patient defaulter tracking by DOT workers; coordinating with the clinical team to provide linkages to home-based care and psychosocial support services; intensive adherence monitoring and support; facilitation of onsite peer support and/or referral to community-based peer support; DOT for HIV and TB medications. Other national care points for TB and TB-HIV co-infection care will include regional hospital inpatient wards, regional Chest Clinics, Infectious Diseases Ward at GPHC, and local prisonscare at these service outlets will be led by FXB-sponsored physicians. Additionally, a national TB/HIV coordinator hired and seconded to the National TB Control Programme in FY'09, will continue to provide overall administrative leadership for the packaging and delivery of TB-HIV services, and the integration of TB-HIV services at primary care outlets nationally.

Key training activities will include clinical mentoring for physicians; annual HCW training on VCT, PPD screening, basics of HIV care; adherence monitoring and support; and informal leadership and management coaching of clinic staff at the Georgetown Chest Clinic. FXB will also provide technical support to PAHO for the delivery of IMAI training.

FXB will continue to support ongoing HEALTHQUAL (CQI) activities at the Georgetown Chest Clinic to ensure that TB/HIV management follows established national standards.

FXB will continue to collaborate with TB/HIV stakeholders on policy issues surrounding TB-HIV co-infection care. Although a national TB strategy exists, it is largely reflective of the required activities and reporting for GFATM funding. In FY'09 FXB and PAHO collaborated to initiate guidance and technical assistance to the National TB Control Programme for the update of the national TB strategy to include operational and M&E plans, and to reflect linkages of donor funded activities; this activity will continue in FY'2010. Other focal areas targeted for technical assistance include improving regional laboratory capacity for sputum microscopy/culturing/sensitivity and instituting laboratory capacity to test for resistance to TB drugs (MDR and XDR-TB). FXB's efforts complement those of the Global Fund and World Bank programs and contribute to a comprehensive HIV response in Guyana. To ensure that duplication of effort is minimized, FXB will continue to contribute to the formulation of national policy and collaborate with the MOH, USG partners, UN partners and other bilateral and multilateral organizations to refine HIV and TB care and treatment protocol.