Linked to Activities 9282, 9283, 9675.

SUMMARY: Activities listed below focus on building the capacity of public tuberculosis (TB) institutions providing counseling and testing services (CT) to offer antiretroviral therapy (ART) and also the capacity to treat and care for patients with multi-drug resistant (MDR) TB. Siguenau is a public, stand-alone TB hospital located in West Regional Department that provides CT services with support from the Global Fund. This hospital is ideally located to serve as a referral center for HIV-infected patients with TB requiring ART and for those with MDRTB. The treatment of patients co-infected with HIV and TB is complicated and requires an experienced team. At present, there is no standardized treatment for such patients. Studies done at GHESKIO centers found that up to 50% of their TB patients are also HIV infected. GHESKIO also found that in Port au Prince, up to 10% of HIV-positive patients may develop MDRTB. The West Regional Department is the most populated region and has the highest prevalence of TB and HIV in the country. At present in Haiti only GHESKIO offers the complete laboratory diagnosis for TB including MDRTB, and only the Partners In Health (PIH) clinic in Cange offers care for patients with MDRTB. Strategies to diagnose and manage TB/HIV co-infection are integral part of the National HIV/AIDS Strategic Plan.

ACTIVITES AND EXPECTED RESULTS: Activity 1: GHESKIO will strengthen Siguenau Hospital's capacity to offer ARV services. A team consisting of one doctor, two nurses, a pharmacist, a social worker, a laboratory technician and two field workers will maintain the activities.

Activity 2: GHESKIO will continue to coordinate all activities between the Sigueneau Hospital and the stand-alone TB clinics. Healthcare providers from other stand alone TB centers will be referred to Siguenau for training in the management of TB/HIV co-infection and identification and referral of MDRTB.

Activity 3: GHESKIO will provide the necessary reagents and supplies to diagnose MDRTB for patients who fail conventional TB therapy.

Activity 4: GHESKIO will build Siguenau Hospital's capacity to become a specialized center providing care to patients with MDRTB. Two GHESKIO clinicians were recently trained at the New York City Health Department in the management of patients with MDRTB. They will work with the MOH staff at the Sigueneau Hospital to establish this capacity there.

Activity 5: GHESKIO TB specialists will participate in the MOH effort to establish national guidelines for the management of TB/HIV co-infection.

Linked to Activities 9672, 9283, 9332, 10241, 9313, 9343.

SUMMARY: Activities listed in this project are carried out to maintain and strengthen anti-retroviral (ARV) services in a national network of public and private health facilities implemented with USG support in FY 05 and FY 06. This will be done through four components: 1) training of providers, 2) technical, administrative and accounting assistance for provision of ARV care; 3) supervision for quality assurance (QA), quality control (QC) and quality improvement (QI) of ARV services 4) capacity building of the public sector departmental hospital in the North, Les Cayes Hospital to become a center of excellence, capable of supervising peripheral centers in its area of influence. Areas of emphasis for these activities will include: community mobilization and participation, reinforcement of existing network and referral system, human resources, infrastructure development, development of local organizations capacity, development of guidelines and training. Specific target population identified will be PLWHA, HIV positive infants and adolescents from 0 to 14 years and affected relatives, caregivers. Activities will cover a) training, supervision, administrative, accounting and technical assistance for fourteen (14) health facilities including eight (8) public facilities and 6 non-governmental organizations (NGOs) in the Ministry of Health (MOH)/GHESKIO network; b) clinical and laboratory training and supervision for twenty-one (21) sites including seven (7) other PEPFAR funded sites; c) capacity building at Les Cayes to become a center of excellence.

BACKGROUND: With FY 05 support, GHESKIO initiated anti-retroviral treatment (ART) services at six (6) sites including four (4) largest public hospitals outside of Port-au-Prince in the MOH/GHESKIO network with a total of 1,200 patients placed on ART. In FY 06 ART has been expanded to six (6) additional sites for a total of twelve (12) sites including five (5) largest public hospitals and will introduce ART to children and adolescents at those sites with the objective to reach a total of 3,000 patients on ART. With FY 07 resources GHESKIO plans to strengthen intervention activities at thirteen (13) sites and build the capacity of the public hospital at Les Cayes as a center of excellence capable to train and supervise three (3) peripheral sites. Hence a total of sixteen (16) sites will provide ART to a total 4,200 patients. In addition, GHESKIO will continue to provide supervision to an additional seven (7) PEPFAR funded sites for a total of twenty-three (23) sites that will received QA/QC/QI. All these activities are part of the national AIDS plan.

ACTIVITES AND EXPECTED RESULTS: Activity 1: The first activity consists of training healthcare providers to offer ART services at twenty-one (21) health centers nationwide. Since COP04, GHESKIO has been mandated by the United States Government (USG) team to train all healthcare providers nationwide and to support the Minister of Health in the certification process of ARV sites. The turn over of personnel justifies continuous training sessions of new personnel and provision of refresher courses because of availability of new knowledge. In the past 12 months, 200 healthcare providers from the public and private sites supported by PEPFAR were trained at GHESKIO for the management of ART. This funding will cover materials and logistics, per diem, lodging of participants and support of trainers.

Activity 2: The second activity is to provide technical (clinical and lab), administrative and accounting assistance to the sixteen (12) sites offering ART services supported by COP06: Les Cayes, Jeremie, Jacmel, Cap-Haitienne, Fame Pereo, Institute of Infectious Disease and Reproductive Health (GHESKIO IMIS), Bombardopolis, Food for the poor, Petit Goave, Hospital Bernard Mews, Centre Eliazar Germain and Signeau. The main items covered by this funding will include: training of providers, support for personnel, adherence support, equipment, logistics and renovation.

Activity 3: The third activity is to maintain and expand supervision and on site training for ART services at twenty-three (23) main sites including three (3) new peripheral sites supported by PEPFAR for QA/QC/QI. These activities are offered since COP05 by the GHESKIO mobile teams. The main items covered by this funding will include: support for mobile teams, per diem, lodging, logistics for visits, materials for supervision / training.

Activity 4: The fourth activity is to assist and reinforce the Les Cayes public hospital in the North Regional Department to become a center of excellence for the South department. This new activity is necessary to decentralize the ARV services and serve as a model for extending services to peripheral sites. There is particular challenging since Les Cayes is the

major public hospital for the department. The South Department is the third most populated region of the country. In this capacity, Hospital Immaculee Conception (HIC) of Les Cayes will be a regional reference and training center, offering training sessions and supervision for peripheral centers in their area of influence. Funding requested will cover renovation for training facilities, equipment, furniture, staffing, logistics for training and supervision and financial support for peripherals sites. The personnel of up to 3 peripheral sites will be trained and will receive regular supervision visits by HIC team, as well as GHESKIO mobile team for QA/QC. TARGETS: 1- Two Hundreds (200) health providers from PEPFAR sites will be trained in ART management, and 100 others will receive refresher courses. 2- Fourteen (14) health facilities from the GHESKIO/MOH/PEPFAR network will offer ART to 4,200 patients, including children throughout a national network. 3- Supervision visits for QA/QC/QI will occur in twenty-three (23) PEPFAR funded sites. 4- The HIC of Les Cayes will serve as the center of excellence for South Department, capable of offering training and supervision to 3 peripheral sites.

Linked to Activities 9672, 9282, 9340, 9923, 10353.

SUMMARY: This activity aims to strengthen the national laboratory capacity of the Ministry of Health (MOH) by helping to establish a quality assurance (QA) program nationwide using dry blood spot (DBS) for HIV antibody testing. The primary emphasis area for this activity is training and technical assistance for QA, quality improvement (QI) and supporting supervision. This activity will be carried out at Haiti's National Public Health Laboratory (NPHL), GHESKIO/ Institute of Infectious Disease and Reproductive Health (IMIS), and designated sites. The specific target population includes public and private health care workers nationwide.

BACKGROUND: GHESKIO/IMIS successfully conducted a demographic and health survey (DHS) using DBS in Haiti in FY05-06. This activity will be initiated in FY07 as part of the United States Government (USG) Team and NPHL's objectives to develop and provide QA /quality control (QC) services to sites conducting HIV screening using rapid testing nationwide. This activity will be supported by the NPHL program and implemented by both GHESKIO/IMIS staff and NPHL staff.

ACTIVITY AND EXPECTED RESULTS: Activity 1: GHESKIO will conduct a workshop to provide the NPHL personnel skills in setting up a QA program using DBS. Staff will be exposed to tools necessary for designing forms, site selection and identification, sample coding, method validation, data analysis.

Activity 2: GHESKIO will conduct training of trainers (TOT) on DBS lab testing for both the national laboratory staff and the GHESKIO mobile team. Training will include two weeks training on spotting cards, drying filter papers, packaging and storing. Method validation will be performed by correlating results obtained from HIV rapid testing, using whole blood on DBS versus Enzyme-Linked ImmunoSorbent Assay (ELISA) results on 100 known samples. Laboratory staff will be trained on cold chain monitoring, participation in the CDC proficiency testing program, and developing QC charts. The GHESKIO/IMIS laboratory at Tabarre, a pioneer site on this type of testing in Haiti, will host this training. The funding for this activity will cover the procurement of tests kits, DBS cards, and other laboratory accessories. Activity 3: GHESKIO will assist the NPHL in of the establishment of DBS HIV testing at the NPHL by ELISA and Western blot. This activity includes instruments verification of plate washers, plate readers and incubator. Split testing of 100 DBS known samples and QA/QC panels from CDC will be used for the method validation. Standard Operating Procedures (SOPs) will be transferred, and a preventive maintenance schedule for equipment will be established. A national DBS QA/QC program will be developed with the NPHL staff.

Activity 4: GHESKIO will train 200 healthcare workers on HIV rapid testing, using whole blood, DBS QA/QC, spotting card, sample processing, drying, packaging and shipping DBS for 97 sites (total of 200 staff). The duration of this activity will be one week, and will be held either at the NPHL or GHESKIO/IMIS for the participants at the designated sites. GHESKIO will also assist the NPHL to conduct a refresher course for DBS, HIV and syphilis rapid testing for additional 200 healthcare personnel.

Activity 5: GHESKIO will provide continuing assistance and support to the MOH NPHL by conducting visits to the NPHL twice a week to go over the DBS testing performed by the NPHL staff. A monthly meeting will be set up with the NPHL, GHESKIO and USG senior staff, in order to report and assess the progress made. Through this activity GHESKIO will continue to build the NPHL' s capacity to properly conduct a QA program and master HIV screening using DBS in order to fulfill its role as a national regulatory body. These activities will improve the capacity of the National Laboratory to provide quality laboratory results in healthcare facilities nationwide.

Activity 6: GHESKIO will develop a training of trainers (TOT) program for the NPHL staff to provide skills and knowledge, in order to further train the national laboratory network sites. The activity will be conducted at GHESKIO for ten NPHL staff to perform tests that are regularly done at GHESKIO. The tests include but not limited to Facscount for Cluster of Differentiation 4 (CD4) enumeration (1 week); ELISA and Western blot (2 weeks); HIV and syphilis rapid testing (1 week); and protein 24 antigen (P24Ag) assay (2 weeks). SOPs for all methods will be distributed to trainees.

Activity 7: GHESKIO will establish quality control procedures of DBS HIV antibody testing at the NPHL in order to improve the quality of lab analysis through: method validation, reference range selection, results analysis, and troubleshooting. This activity will require the participation of a Quality Assurance manager, a Coordinator, a laboratory supervisor, and a biomedical engineer. The latter personnel will provide equipment services to the NPHL, the national laboratory network sites and GHESKIO laboratories.

Activity 8: GHESKIO will establish early infant diagnosis (EID) of HIV infection by dried blood spot polymerase chain reaction (PCR) at GHESKIO, PIH and at the national lab to immediately offer diagnostic services to 2200 babies born to HIV-infected mothers. GHESKIO will send 2 lab trainers to be trained at CDC Atlanta. GHESKIO will train 10 GHESKIO, 2 PIH, and 2 NPHL lab techs to be capable of performing DBS collections and DBS PCR. GHESKIO will procure 3 sets of laboratory equipment and accessories needed to equip the three labs. The test kits and supplies will be provided by the Partner For Supply Chain Management (PFSCM). GHESKIO will train two personnel at each 100 PMTCT centers (200 staff) in the collection, preparation, storage, and shipment of specimens. Conditioned specimens will be sent once a week in specific shipping containers from various peripheral sites to referral departmental laboratories and stored in proper storage cabinets. Once a week specimens will be shipped from the departmental labs to the GHESKIO lab at IMIS to be tested by the DBS PCR method. GHESKIO will also provide internal QC testing by testing fifteen percent (15%) of the specimens by the EasyQ method. GHESKIO will also enroll in the CDC pediatric diagnosis QA/QC program,

TARGETS: 1 workshop conducted 16 trainers trained in DBS testing and QA/QC 1 DBS QA/QC lab at the NPHL established and operated 200 laboratory personnel trained in whole blood rapid HIV testing, DBS collection and DBS QA/QC 1 national DBS QA/QC regularly guided 12 members of NPHL staff trained in HIV laboratory methods 200 healthcare personnel trained for DBS, Syphilis and HIV rapid testing 97 Service outlets able to perform proper blood collection on filter paper (DBS) 16 lab techs trained to perform EID by the DBS PCR 3 labs able to offer laboratory services for EID of HIV infection 2200 babies born to HIV-infected mothers diagnosed 200 PMTCT staff trained to proper collect store and ship DBS from babies

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Table 3.3.15: Program Planning Overview Program Area: Management and Staffing Budget Code: HVMS Program Area Code: 15 Total Planned Funding for Program Area: $ 4,337,000.00

Program Area Context:

The United States Government (USG) Haiti HIV/AIDS program budget has increased from the $6 million United States Agency for International Development (USAID) HIV/AIDS program in FY03, to a combined total of more than $68 million planned for the President's Emergency Plan for AIDS Relief (PEPFAR)/Haiti program in FY 2007. This makes PEPFAR the largest HIV/AIDS donor in Haiti. The Centers for Disease Control and Prevention (CDC) opened its country office in Haiti in 2003, to co-manage the USG HIV/AIDS PEPFAR-funded program, complementing the then-current USG efforts, chiefly in the prevention sector, with expertise in laboratory support, clinical care and treatment services, information management, and efforts to build host-country capacity in each of these areas. USAID has been implementing HIV/AIDS programs in Haiti for more than 20 years, focusing on prevention interventions, community level support and care for people living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVC), condom promotion, and screening and treatment of sexually-transmitted infections (STIs), as well as systems development and capacity building in the nongovernmental (NGO) and public sector.

The USG Team coordinates closely with the Government of Haiti (GOH)'s Ministère de la Santé Publique et Population (MOH), and other donors, in health and HIV/AIDS, and maintains a close relationship with the Global Fund for AIDS, tuberculosis (TB), and Malaria (GFATM) for coordination of planning and monitoring of projects and commodity purchases. USAID and CDC both strive to emphasize their competitive advantages and leverage agency strengths in the respective program areas, while at the same time complementing each other's efforts through active collaboration in program planning and operational management (e.g. joint staff meetings, site visits, sharing of best practices).

As of September 2006, the USG Team has 60 positions, 43 of them full-time working on PEPFAR activities and programs. All but four of these are currently filled and recruitment is underway to fill these. It remains difficult to recruit and retain both technical and management staff for the USG Team in Haiti because of a reluctance on the part of expatriates to live and work in the unstable, unpredictable environment of Haiti and because a large percentage of well-qualified Haitian technical experts have left the country to live elsewhere.

The staff skills necessary to ensure efficiency, reasonable costs and long-term sustainability of the USG investment in Haiti is a mix of high-level technical leadership to assist the national AIDS effort with establishing vision and over-all coherency of programming and experienced program managers and monitors to carry out operational planning and field monitoring and supervision. There is also a continued need for substantial numbers of support and administrative staff due to the level of insecurity and lack of efficient systems and infrastructure in Haiti. This requires the constant use of chauffer-driven (and usually armored) vehicles and increased personnel for security purposes and for compensatory support for everyday systems that do not function. Long-term sustainability will be achieved by the USG staff working side by side with government and other local technical advisors and project monitoring personnel to train and to establish together the systems, procedures and infrastructure that will be left in place at the end of the 5-year PEPFAR initiative.

Only two agencies of the USG Team have established local offices, CDC and USAID, and they are both housed in the USAID Mission, thus facilitating communication and daily coordination. Peace Corps traditionally has a strong presence in Haiti; however, they pulled out in April 2004 with the violent overthrow of President Aristide and, due to the continued high level of instability and insecurity in the country, have not returned. If a Peace Corps presence is reestablished in FY 2007 and volunteers are allowed to return, this will be reflected in management and staffing patterns for FY 2008

CDC and USAID agencies have worked to remain complementary in their technical oversight functions and take care not to be duplicative in their hiring of technical specialists. Thus, USAID has technical advisors/program managers for OVC, PMTCT, TB/HIV, behavior change communication for prevention,

counseling and testing (CT) and drug and commodity procurement, while CDC has technical advisors/program managers for facility-based prevention (blood safety, injection safety, treatment of sexually transmitted infections [STIs]), facility-based palliative care, ARV services, laboratory infrastructure, strategic information and policy analysis and systems strengthening.

CDC Haiti is exclusively devoted to PEPFAR implementation whereas USAID's Health Office manages PEPFAR as one element of its many-faceted health portfolio. Thus, while all of the technical advisors, program managers and support staff on the CDC team work full-time on PEPFAR, USAID has only one full-time PEPFAR staff person and part time support from all other technical, management and support staff.

The FY 2006 Country Operational Plan (COP) highlighted plans to recruit for the PEPFAR Country Coordinator position. This was not acted upon due to the departure of the Chief of Mission (CoM) in early 2006, his replacement with a Chargé d'Affaires, and then the subsequent arrival of a new CoM in March 2006. The current CoM has focused on national presidential and parliamentary elections and the appointment of a new Cabinet and has not yet turned her attention to the PEPFAR Coordinator position. The current USG Team expects this will happen early in FY 2007; therefore, the FY 2007 Management and Support budget includes sufficient funding for the recruitment of a PEPFAR country coordinator.

A new U.S. Embassy Compound to house all offices and agencies of the USG in Haiti is under construction in the Tabarre area of Port-au-Price, near the airport. USAID, CDC and all USG agencies will be moving to the new location in early 2008. A "head tax" is being levied in FY 2007 on all agencies to support this construction.

The total planned spending on management and staffing for FY07 does not exceed 7% of the total planned budget for the year.

Table 3.3.15: