The Guyana Ministry of Health works to combat HIV are through promotion of informed and responsible behaviors and healthier lifestyles, reduction of morbidity/mortality due to STI/HIV/AIDS and reduction of the psycho/social/economic impact of STI/HIV/AIDS, especially in pregnant women, blood donors, TB infected patients and MARPS. The program spans all ten administrative regions of Guyana with a network of 165 facilities. In FY 12, this IM will specifically support the MOH in improving sexual health for the people of Guyana, improving program management and coordination, promotion of safer sexual practices through IEC programs, improving surveillance, care and treatment, establishing special HIV/AIDS prevention and control programs and effective management and evaluation the HIV/AIDS programs.

Over time, the MOH will increase efficiency through decentralization of HIV care and treatment, training and empowering a diversified cadre of workers to deliver HIV care and treatment to the population with universal coverage and utilizing evidence based and cost efficient methods to deliver services. The MOH will also assume more responsibility and eventually take complete ownership of the program. Training of staff at the National AIDS program Secretariat and other facilities in monitoring and evaluation will intensify during FY 12 and 13 so that provision of care will be more evidence based and accountability will improve.

The Cooperative Agreement of CDC with Ministry of Health supports HIV adult care and support in facilities and community settings. The main types of care and support services provided to persons living with HIV/AIDS are Home based care for clients who are in need, provision of pharmaceuticals for illnesses such as diarrhea and Opportunistic Infections, laboratory investigations, pain and symptom relief, psychological and spiritual support and end -of- life care and bereavement services, safe water interventions, nutritional assessment and counseling support. Preventive services include partner/couples counseling, testing and support, STI diagnosis and treatment and family planning, counseling and condom provision. All of these types of services take place at the community or health facility settings. At the health facility level services such as provision of pharmaceuticals, clorosol and provision of IEC materials for safe water. Home based care nurses provide services in the community. These include psychological and spiritual support and end of life care. Community support groups some non-governmental organizations, relatives of clients and home based care nurses form linkages between program sites and non-HIV specific services such as food support.

In previous years PEPFARs, support for TB/HIV was mainly through technical support provided by the local CDC office and funding through implementing partners such as PAHO and FXB. For FY2011 the NTP will continue to receive direct funding as part of the Ministry of Health CoAg to expand and strengthen the quality of services and information related to the TB/HIV activities in-country, with coordination from CDC and their implementing partners.

The National Tuberculosis Program (NTP) in collaboration with the National AIDS Program Secretariat (NAPS), and its partners has developed the country's strategic plan as well as set guidelines for TB, HIV and TB HIV patients.

The NTP plans to scale up the DOT HAART initiative to improve the management of dually infected patients in at least 6 of the 10 regions in Guyana.

This will include the supervision of the administration of TB medications as well as at least one dose of ARVs and ongoing monitoring of the clinical status of co-infected patients. The funding will continue to support the recruitment of a DOT HAART supervisor and a social worker as well as facilitate the training of existing DOT workers.

The NTP through their surveillance, monitoring and evaluation of TB/HIV collaborative activities has been able to report data and track progress towards stated objectives.

From the reports received there has been achievement in the percentage of TB patients who had an HIV test result recorded in the TB register of 90%.

The care of HIV patients co-infected with TB at the TB clinics needs to be improved as well as the care of HIV patients who has latent TB at the HIV care site needs to be improved. The TB patients who are diagnosed will continued to be managed at the TB clinics with their appropriate ART while there will be the implementation of IPT at HIV care sites for the HIV patients with latent TB.

In COP 12 MOH will renovate one of the buildings in the hospital compound in Georgetown to provide step down care for Multi Drug Resistant (MDR) TB, including those co-infected with HIV and other complicated TB cases. MDR TB is an emerging phenomenon in Guyana. The National TB Program (NTP) has developed a draft strategic plan to prevent and control the emergence of MDR TB in Guyana in response to the emergency. The step down care facility is an integral component of the plan to combat MDR TB. It will not only allow for the inpatient care for MDR TB cases for at least 4 months but will also assist in the rehabilitation of patients through stepwise re-integration into the community.

COP 12 and 13 will continue to support the MOH in its provision of pediatric care and support in its facilities. The target population for pediatric care and support will be all HIV exposed infants and HIV infected children and adolescents who are not on ART. The MOH will intensify Early Infant Diagnosis of HIV through DNA/PCR testing of Dry Blood Spots on exposed infants between six and eight weeks of age. This will be facilitated by full implementation of the Case Tracking System. Scale-up in diagnosis also include intensifying antibody testing of children for HIV at 12 and 18 months of age and beyond or those who may have missed earlier diagnosis and occasionally for those who were being breastfed. The COP supports provision of cotrimoxazole to exposed infants as prophylaxis from six week of age until they are diagnosed HIV negative and for HIV infected infants to prevent opportunistic infections. In COP 12 and 13 screening for TB and Pneumonia will be an important activity during the pediatric period.

Adolescents who are HIV-infected are educated about the disease once disclosure is made to them about their illness. Particular emphasis is placed on adherence counseling and Prevention With Positives counseling as they prepare to enter into adulthood. Nutritional evaluation will be continuously done.

The Ministry of Health will continue to support activities that support improved quality of care and strengthening of health services including constant review of data and records, ensuring that those in care are not lost to follow-up. The Case Tracking System will ensure that clinic attendances are improved.

Activities that the MOH will use to promote integration of pediatric care, nutrition services and MCH services include taking anthropometric measurements, laboratory assessments , nutritional evaluations in children attending MCH clinics with Provider Initiated Counseling and Testing when necessary. Nutritional support counseling of mothers/guardians will be intensified. The MOH will continue to strengthen its health facilities to provide laboratory support so that diagnoses of co-morbidities can be made.

The Ministry of Health will continue efforts to strengthen laboratory services and infrastructure in Guyana. The goal of the MOH laboratory activities in COP12 and COP13 will be to improve the quality of life and survival of PLHIV by providing access to quality assured laboratory services for HIV diagnosis, care, and treatment.

The quality of laboratory services at both the national and regional levels will be enhanced with the Health Facilities Licensing Act which came into effect in April 2008 and which requires all laboratories to be certified by the Guyana National Bureau of Standards (GNBS). NPHRL is already certified by the GNBS to GYS170:2003 (based on ISO17025) and is currently working towards international accreditation. Two of the regional laboratories Linden and New Amsterdam are working towards GNBS certification by the end of FY12. In COP12 and13 MOH will continue to participate in international and local External Quality Assurance (EQA) programs. Additionally in COP12 and 13 MOH will support QA managers at NPHRL to travel to regional/district laboratories and HTC sites to provide oversight, training and assessment in compliance with QA programs.

The coverage of public laboratory services extends to five levels: health post, health center, district hospital laboratory, regional hospital laboratory, and tertiary laboratory. Health posts and centers which are also VCT sites are found throughout Guyana and provide other services such as malaria smears and possibly hemoglobin, while district level facilities perform basic testing such as hemoglobin, complete blood count (CBC), urinalysis, and blood glucose. At the regional level there are 4 regional laboratories in Guyana (Linden, Suddie, West Demerara, and New Amsterdam).These regional laboratories are all located on the coast of Guyana where the HIV epidemic is more prevalent. In addition to HIV testing the regional laboratories have the capacity to provide automated chemistry and hematology. All diagnostic and clinical monitoring functions such as CD4, Viral Load and Early Infant Diagnosis for PEPFAR programs are performed the NPHRL which is the only tertiary laboratory in the country.

Training activities have been developed to ensure continuous improvements in human resources. Laboratorians from Microbiology, TB, Molecular Biology and Serology departments will be trained in validation of new techniques including Nitrate Reductase Assay and Line Probe Assay for TB, EIA for toxoplasmosis and CMV, and fluorescence microscopy for PCP. Furthermore QA managers at NPHRL will conduct remedial training in quality assurance and laboratory testing while senior staff at NPHRL is expected to be trained in laboratory management.

In COP12 and 13, MOH laboratory activities will continue to be aligned to the objectives of the National Strategic Plans for Medical Laboratories 2008-2012 and 2012 2020. To facilitate seamless transition and sustainability CD4 testing for the two faith-based institutions i.e. St Joseph Mercy Hospital and Davis Memorial hospital will continued to be provided by NPHRL even as CRS (AIDsRelief) transition expansion of ARV therapy programs including expansion of high quality HIV care, prevention and treatment activities in faith based-affiliated sites.

In FY 2012, CDC will continue support MOH SI in following 3 categories:

1. Personnel: support staff needed for implementing surveillance system and institutional review board (IRB);

2. Training: continue support trainings of surveillance staff and IRB members.

3. Supplies for Management of IT and Surveillance system, this include the overall required electrical infrastructure and support for the WAN deployment within the MOH Brickdam complex and across its external administrative sites, the implementation of the virtual library infrastructure and an internal network, as well as stationary supplies for the surveillance of the Ministry of Health

CDC will continue to work in close collaboration with the Ministry of Health (MOH) including the National AIDS Programme Secretariat (NAPS) office, the National Blood Transfusion Services (NBTS), and Implementing Partners to strengthen and support strategic information (SI) activities including health management information systems (HMIS), surveillance, monitoring and evaluation (M&E), and programmatic research. In FY12, CDC will emphasize improving SI systems in the MOH and at NAPS, will work to improve coordination between the national statistics unit and various program areas, and provide technical assistance to the Government of Guyana technical committee for the review of Prevention of Mother to Child Transmission (PMTCT) data collected at Antenatal Clinics (ANCs).

CDC will provide technical assistance to the MOH for use of the National Patient Monitoring System (PMS). CDC will assist the MOH in completion of the National Epidemiologic Profile begun in FY07. In addition, CDC will collaborate with USAID and GHARP II to assist the Government of Guyana to revise the National HIV/AIDS M&E Plan and National Strategic Plan (NSP) on HIV/AIDS. Specific support to the MOH includes short-term technical assistance (TA) and targeted trainings in data management, surveillance, M&E and research methodology and planning.

Since FY2009, CDC provided ethics and research training for over 50 persons in Guyana and assisted with MOH with the establishment of Guyanas first Institutional Review Board (IRB). In FY2012, CDC will continue to provide guidance to the MOH IRB.

Lastly, CDC will continue to work with MOH to strengthen routine program reporting utilizing standardized reporting systems that minimize redundant efforts for different reporting pathways. In recognition of the human resource shortages that inhibit strong SI programs in country, CDC will assist with training and mentoring of MOH staff. A portion of the CDC direct-hire Epidemiologist position and the National Alliance of State & Territorial AIDS Directors are supported through the SI program activity.

Build institutional capacity of public MCH clinics to provide care of HIV exposed infants through training, technical assistance, task shifting from physicians to medex and nurses, and development of appropriate SOPs. Support for updating of National Blood Safety Strategic Plan and Quality Management.

The National Blood Transfusion Service (NBTS) of the Ministry of Health will continue to improve in areas that are critical to the safety, quality and availability of blood products. Primary objectives for FY2012 include blood collection that will encompass revision of policies and procedures to have quality systems in place while at the same time implementing best practices and evidence based strategies. Additionally training and mentoring of new staff and further training for collaborators and volunteers will be done during the next two years. To ensure efficient blood collection blood donor recruiters and the management of NBTS will coordinate and schedule a number of blood drives with projected numbers of collection. The implementation in 2011 of the Delphyn, blood banking data management system from Diamed is critical to ensure process control and standardize processing. With regards to Testing and Processing, during 2012 and 2013 all blood collected by the NBTS network will be tested for Syphilis, HIV, HBV, HCV, Malaria, Micro-filaria and HTLV 1&2 and Chagas, all testing for TTIs will continue to be centralized at NPHRL; testing, processing and preparation of components will be done by NBTS.Integration of blood safety with other HIV/AIDS servicesBlood safety activities are closely integrated with the Laboratory Infrastructure program the Director of the National Public Health Reference Laboratory (NPHRL) is tasked with managing the daily operations of the NBTS and all testing for transfusion transmitted infections (TTIs) is done at the NPHRL. Blood safety also has linkages to maternal health aspects of the PMTCT program, patient referral systems and confidentiality issues under counseling and testing: and data management and collection under Strategic Information.Coverage and scope of blood safety activities including geographic coverage

There has also been an increase in the number of voluntary non-remunerated blood donation during the period 2004-2010 with a concurrent decrease in the number of family/replacement blood donations. Blood collection and storage is currently performed at six public sites in Guyana. Six private hospitals access blood for transfusion directly from the NBTS. Twelve (12) public and private hospitals perform blood transfusions. These sites are located in regions 2, 3, 4 (includes the capital, Georgetown), 6, and 10.

Target Populations: Healthy adults, principally youth, are targeted for recruitment as blood donors. Women and children with anemia due to malaria, complications of surgery or childbirth and trauma accident plus patients who become anemic as a result of HIV antiretroviral medication will be the primary beneficiaries of a safe blood supply. How blood safety activities foster country ownership and sustainability.

The NBTS will work in collaboration with the CDC/GAP Guyana office, to achieve program outcomes. All activities implemented under this program will follow national policies and guidelines for the delivery of blood safety interventions. During 2012, Supply Chain Management System (SCMS) will transition the procurement of materials and consumables (e.g. test kits and reagents) to the MOH, Materials Management Unit (MMU).

The Ministry of Health through COP 12 will support targeted provider initiated testing and counseling of patients and partners seen in STI, TB and HIV care and treatment sites. The clinical facilities that will be supported for these activities will be The National Care and Treatment Center, the Georgetown Chest Clinic and the mobile medical clinic that services the hinterland communities.

The testing algorithm used will be similar to the national algorithm.

MOH will intensify activities to ensure that clients who are tested HIV positive are enrolled in care and treatment through intense counseling, emphasizing the importance of starting treatment early.

Quality assurance of testing and counseling will be done by ensuring that counselors and testers are adequately trained and periodically retrained and their performance monitored through Quality Assurance methods.

The uptake of Counseling and Testing by couples will be used as a measure of effectiveness of HTC.

STI management of at risk youth and pregnant women. Targets geographic areas with high STI morbidity.

In COP 2012 Ministry of Health, Guyana will continue to support the PMTCT program to effectively screen pregnant women and their partners to prevent the transmission of HIV and provide adequate care and support for those already infected. PMTCT HIV counseling and testing services are now available at 157 sites countrywide, including antenatal clinics and labor and delivery wards, however, there are only 19 HIV care and treatment sites that are capable of providing prophylaxis treatment for HIV-infected pregnant women. During FY 2011, 82.9% of pregnant women knew their HIV status, unfortunately, many of those who are HIV infected do not receive a complete course of ARVs prior to delivery. Some clients still experience problems in accessing care because of long distances that they need to commute in order to receive prophylaxis at one of the 19 care and treatment sites. To address this issue, during COP12 the MOH will further decentralize care, build capacity and empower more staff.

During the scalingup of PMTCT program, the high cost of hiring International facilitators, advisors and travel and subsistence to low prevalence hinterland areas contributed significantly to the high cost per patient for PMTCT services. Measures that can decrease the unit cost for reaching patients include further decentralizing PMTCT service. The MOH has begun to address this by training MEDEX to deliver service to the hinterland regions. In addition there are now more trained local staff available to deliver services. The MOH will continue to encourage partner testing for HIV, discordant couples counseling and testing and consistent family planning for HIV positive mothers. The MOH will enhance and evaluate their Case Tracking and Management system. This system entails Case Managers tracking infected mothers and their newborn infants after delivery. Several PMTCT activities are well integrated into MCH, including HIV counseling and testing, Rapid Testing at Labor and Delivery wards and ELISA testing for HIV at the National Public Health Reference Laboratory. However, provision of ART is not well integrated. The MOH will address this barrier by further decentralizing PMTCT services.

In COP 2012 and 2013 the Ministry of Health will continue to build on successes under COP 2011 and provide training to clinicians. Training will involve mainly physicians who graduate from the University of Guyana and graduates from Cuba. Physicians will be trained under the guidance of the National AIDS Program Secretariat and National Care and Treatment Canter (NCTC) in all aspects of ART of People Living with HIV/AIDS. These physicians will receive didactic as well as mentorship by experienced physicians to ensure appropriate application of skills to the clinical setting. The MOH will also train MEDEX, a category of clinical health assistants, nurses and community health workers in ART.

The Ministry of Health under the COP provides on-site supervision at the NCTC and through the mobile unit to treatment sites in the hinterland regions of Regions 1, 7, 8 and 9. Supervision is done by senior MOH physicians to junior physicians and in the case of the hinterland regions to MEDEX as well. The MOH tracks clinical outcomes by using the data of clinical examinations and laboratory monitoring, through routine CD4 and Viral Load testing. While the majority of adults currently on first line ART have good outcomes a small minority experience treatment failure and are on second line ART.

At the site level, performance measurement data is examined and discussed periodically by multidisciplinary teams who assess the data from different perspectives and take corrective measures.

The MOH supports several activities aimed at retention of patients on ART. These activities are geared to ensure that patients are not lost to follow-up. They include encouragement of treatment buddies, linkage to home-based care nurses and social workers.

PEPFAR supports the MOH to implement measures to maximize adherence. These include intense pre-initiation adherence counseling by pharmacists, social workers and clinicians and at least one session involving a group of patients for initiation. The first clinic attendances after initiation are shortened, usually two weeks apart and patients are closely followed and advised how to deal with adverse drug reactions and other issues. At every subsequent visit adherence counseling is given and the recall method is applied and in some cases pill counts are done. These activities are generally successful in achieving a high level of adherence.

The target population for ART for the MOH is all adults who meet clinical criteria for ART, including pregnant women, adults with high risk behaviors, patients co-infected with TB and other opportunistic infections. All HIV-infected patients are screened for TB and cotrimoxazole prophylaxis is widely applied according to treatment guidelines in all patients co-infected with TB disease.

Some activities that the MoH has undertaken in order to improve programmatic efficiencies to allow for continued expansion of services include rationalizing the frequency and schedule of laboratory investigations e.g. viral load testing commences in adults at six months after initiation of ARVs and is repeated at six month interval thereafter. Other activities are training of MEDEX to manage and treat HIV infected persons in the hinterland communities and decentralizing HIV treatment activities.

The Ministry of Health revised Pediatric Treatment Guidelines for HIV in COP 2011. These guidelines are now in effect in the National Care and Treatment Center which is the main facility for pediatric HIV/AIDS treatment in Guyana. During COP 2011, 39 males and 31 females in the 0 to 15 age dgroup were placed on ART. During COP 2012 and 2013, treatment targets in this age group will be 8o and 90 respectively.

In COP 2012 and 2013 the Ministry of Health will continue to train clinicians to deliver pediatric care and treatment at all treatment sites. The National Care and Treatment Center will be the main facility where mentoring of physicians for pediatric treatment will take place. Other categories of health care workers such as nurses, counselors, social workers, MEDEX, pharmacists, community health workers will also be trained to build a cadre of caregivers for all MOH treatment facilities.

The MOH will continue and intensify training and retraining of program supervisors at the national, regional and district clinical site levels to routinely collect data and monitor the quality of service. In this regard, in COP 2012 there will be training and support of supervisors in monitoring and evaluation.

The MOH will intensify adherence counseling to parents/guardians of children and adolescents on ART. During COP 2012 and 2013 full implementation of the Case Tracking System will significantly minimize the loss to follow-up of mother/infant and other children on treatment. Full integration of pediatric care to MCH services in addition will improve the retention of infants and children on treatment.

The MOH will continue to promote integration of pediatric treatment services into MCH platforms of service delivery and other services in the community. The integration of PMTCT program into MCH services will ensure that infected children receive the care that uninfected children receive, including evaluation and intervention for nutritional deficiencies.

Training and retraining of staff in the technique of sample collection through Dried Blood Spots will continue in the COP 2012 and 2013. Care providers will be trained at central, regional and district levels in PITC so that siblings of HIV infected children, children of HIV-infected mothers and adolescents will be evaluated. CD4% and Viral Load testing will be done according to guidelines for pre-ART pediatric clients and those on ART. CD4 testing is decentralized to 2 regional hospital laboratories and will be further decentralized. Since Viral Load testing is done only at the National Public Health Research Laboratory, samples will be collected from children on treatment from all MOH facilities and taken there for analysis.

The MOH will ensure that adolescents in treatment will receive intense education and counseling to understand the significance of HIV/AIDS and their condition, emphasis being placed on the importance of adherence and how they can improve their quality of life. As they transition to adulthood, they will be given Prevention With Positives counseling.

The MOH will intensify training in Strategic Information for its staff at the various levels in collaboration with CDC. Systems for data collection and analysis will be implemented and strengthened at all levels.