Linked to Activities 8160, 9314,10415,9309,9313,9311,9310,9312.

SUMMARY: Close to 15 public facilities currently provide services that range from counseling and testing (CT) to antiretroviral combination treatment (ART). In FY 2005 and FY 2006, the USG Team supported hiring of additional staff and training of staff through a cooperative agreement with the Ministry of Health (MOH). A number of facilities continue to remain inadequately staffed and equipped for PMTCT services. The network of USG-supported public health facilities sees about 60,000 pregnant women a year, of whom 10,245 had been tested between October 2005 and June 2006. Of the 300 women who tested HIV positive only 30% received a complete package of prophylactic treatment. There is a need in FY 2007 to continue to reinforce PMTCT services within the network of public health facilities in order to test at least 90% of pregnant women attending those facilities (54,000) and provide prophylaxis to at least 80% of the estimated number of those who test positive.

In FY 2005, although no specific funding was allocated to the network of public sites, PMTCT activities had been initiated, tapping into resources allocated for other program areas. In FY 2006, 12 public sector sites with the highest attendance are receiving USG support to strengthen their PMTCT interventions. The sites within the network are expected to test 40,000 women and put 768 infected women and their babies on ARV prophylaxis by the end of September 2007. This support should also help the MOH enhance the effectiveness of its interventions, through integration of PMTCT services into antenatal care clinics and maternity wards; the provision of counseling services by all providers in maternity wards; adoption of a companion (accompagnateur) strategy to ensure treatment compliance; dietary assessment and counseling for both the mother and options for feeding her infant; in-depth education of HIV-positive pregnant women and their accompagnateurs on a list of key issues (nutrition, getting partners and other children tested, protection in a discordant couple situation) ; and support for social workers and community health agents to track pregnant women and their babies.

ACTIVITIES AND EXPECTED RESULTS:

The MOH will support PMTCT services at its 12 existing sites and expand its support to three additional sites within the public sector service delivery network for a total of 15 sites.

Activity 1: The MOH will provide a full package of PMTCT services, as outlined in MOH national guidelines, including: • counseling and testing (CT); • tuberculosis (TB) screening with all pregnant women with TB referred for treatment ; • sexually transmitted infection (STI) testing and management; • reproductive health services, particularly family planning counseling for HIV-positive women including promotion of condoms; • case management of HIV-positive pregnant women, including eligibility assessment for ARV treatment with Cluster of Differentiation 4 (CD4) determination and will be referred for treatment in accordance with national guidelines; • psychosocial support; • nutritional assessment and dietary counseling for mother; • counseling and education for informed choice on infant feeding in the first six months as well as appropriate weaning and continued feeding of child; • short-course ARV prophylaxis regimen for HIV-positive women according to national guidelines; • prophylaxis of opportunistic infections (OIs); and • safe obstetric care.

In addition to training in emergency obstetric care, the MOH will train staff in delivery techniques that minimize exposure of the baby to the blood and secretions of the mother (artificial rupture of membranes, episiotomy only when needed, and suction of the mouth of the newborn). Further, personnel will be trained to protect themselves and their patients against HIV through the use of gloves and protective glasses, the use of sterile instruments, disinfectants etc. After delivery and post-natal services, HIV-positive mothers and their babies will be referred to HIV/AIDS treatment and care centers for clinical care follow-up.

Activity 2: The MOH will improve program retention of HIV-positive pregnant women by ensuring the cost of hospital visits and hospital delivery are covered including transportation to the hospital. The PMTCT sites will implement a tracking system for the enrolled pregnant women through community health agents and traditional birth attendants (TBA) working with USG-supported community based organizations. In many of the regional departments this community support will be augmented by engaging Mothers Clubs that are part of the Title II Pl480 partner network.

Activity 3: The MOH will promote PMTCT services via community events including health fairs, face-to-face communication using a variety of channels such as churches, schools, health facilities, home visits, and the media. To encourage pregnant women to be tested for HIV, the USG Team will support the MOH in developing posters, brochures and other materials to be used in prominent locations in antenatal clinics. Furthermore, the MOH will organize community testing days, on patron saints days, and on special days (i.e. International AIDS Day, Candlelight Vigil Day, etc.). with public service announcements within the targeted communities, banners and street signs to make the population, and particularly pregnant women, aware of this opportunity.

Activity 4: The MOH will provide continuing education sessions for staff to keep them abreast of new developments in PMTCT, particularly the psychological aspects in post-test counseling sessions for HIV-positive pregnant women. In collaboration with John Hopkins Program for International Education & Gynecology Obstetric (JHPIEGO) and I-TECH supported Haitian Institute for Community Health (INHSAC) training sessions, will be held onsite to ensure participation of the personnel.

Linked to Activities 9308, 8160, 10415, 9309, 9313, 9311, 9310, 9312, 9333.

SUMMARY: The Ministry of Health (MOH) is the primary regulatory entity for health care service delivery in Haiti, including HIV services. It is also the most important provider of health services, with a network of dispensaries, community hospitals, regional departmental hospitals and a University Hospital. With support from the President's Emergency Plan for AIDS Relief (PEPFAR), counseling and testing (CT) services have been developed at numerous public facilities. The challenge has been to retain patients that test positive for HIV and enroll them into HIV care and support services. With FY05 and FY06 funding, PEPFAR has provided resources to 16 MOH sites to develop a wider range of services including psycho-social support, clinical management and biological monitoring for non-ARV patients. The MOH network was able to enroll approximately 3,000 HIV-positive patients in palliative care programs as of June 2006. Additional support in FY07 will expand the number of MOH sites to 25 and bring the total number of patients receiving palliative care within the MOH network to 20,000 by September 2008.

BACKGROUND: Of the 650 health facilities operating in Haiti, close to 90 now offer CT and PMTCT services, including 19 of the most prominent public sector facilities. Their operations have been sustained through the infusion of PEPFAR resources in terms of personnel, materials, equipment and supplies. When CT services were first initiated with limited staff and scope, a key problem was how to deal with HIV-infected individuals once they were diagnosed. With PEPFAR support, the 19 sites have evolved from a minimal CT model to one where counseling is offered at all the wards and where new categories of personnel such as nurses, social workers, and community health agents have been added to reinforce care and offer patients a more comprehensive package of services. The 19 sites now have the capacity to enroll patients into palliative care, provide initial and follow-up care using a specialized medical record that allows longitudinal tracking of information, carry out prevention and management of opportunistic infections (OIs), offer psycho-social support to the patients and their families, and perform basic biological monitoring.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will enhance clinic-based activities for management of OIs through appropriate diagnosis and treatment and organization of psychological support services. Funding will cover the cost for a trained multidisciplinary team composed of a physician when necessary, a dedicated nurse, psychologist or social worker located at important sites, and staff at other sites trained in psychological support; basic office and medical equipment and supplies; and utilities such as water, communication, and power. The MOH will enroll every person who receives a positive HIV test into a palliative care program designed to monitor the patient's status, prevent and manage OIs, and provide psycho-social support according to the national norms and protocols.

Activity 2: The MOH will strengthen its outreach capacity through a network of community health workers (CHWs) working under the supervision of the site social worker. CHWs will serve as the principal liaison between the health facility and people living with HIV/AIDS (PLWHA). Additional CHWs will be hired and trained to promote CT and PMTCT services; conduct home visits of PLWHAs; ensure adherence to drug regimens; provide advice on personal care; identify or help develop self-support groups to which PLWHAs could be enrolled; help plan community meetings to dispel myths about HIV and combat stigma; refer PLWHAs needing acute care to the nearest health facility; and refer PLHWAs in need of economic or nutritional support to the appropriate agency.

Activity 3: The MOH will organize PLWHA support groups around the existing sites to create a setting for patients and their families to share knowledge and experiences. It has been noted that participation in support groups has improved patient adherence to treatment as well as their acceptance of the disease.

Activity 4: The MOH will subsidize critical costs linked to services, such as transportation for patients and their companions to sites for treatment and other services.

Activity 5: Particular emphasis will be placed on linking all MOH palliative care sites with ARV sites, to ensure that eligible patients get access to ART. These sites will also be equipped to do required follow-up for patients on ART in order to limit time-consuming

and costly travel to the ARV sites. This network model is being piloted in the South Regional Department of Haiti this year and will be expanded to other departments in the near future. The palliative care sites will be linked to the prime CBOs receiving USG resources for social support services.

Activity 6: The MOH will address sustainability by developing permanent core competencies for community mobilization in order to maintain a more supportive environment for care and support for PLWHAs. Training of trainers (TOT) and facilitators will be conducted in order to develop permanent community capacity for a cohesive community response on behalf of affected households. This will translate into heightened community and social mobilization, with advocacy at all levels to leverage community and institutional inputs across sectors.

SUMMARY: The Ministry of Health (MOH) is the primary regulatory entity for health care service delivery in Haiti, including HIV services. It is also the most important provider of health services, with a network of dispensaries, community hospitals, regional departmental hospitals and a University Hospital. With support from the President's Emergency Plan for AIDS Relief (PEPFAR), counseling and testing (CT) services, care and treatment services, including TB/HIV have been implemented at numerous public facilities. The challenge has been to reinforce infrastructure, equipment and human capacity to provide quality services at these facilities. The MOH network was able to enroll approximately 3,000 HIV-positive patients in palliative care programs as of June 2006. Most of the public sites lack equipment and materials to perform chest XRays for TB diagnosis. Support is needed to make available this diagnosis capacity at some of the major public sites (about 20) in order to enhance TB/HIV services. This effort will be integrated in existing effort to reinforce human capacity, infrastructure, lab and logistic to expand HIV services at these sites.

BACKGROUND: This year, the TB/HIV program has been producing excellent results. Based on MOH norms and policies, most of the CT, care and treatment centers have been capacitated to perform TB screening and diagnosis with PPD test sputum smear and to provide INH prophylaxis. In addition, HIV testing and palliative care services have been fully implemented in at least 7 major TB clinics in the metropolitan area. These services are being expanded to 25 other TB clinics this year. The TB/HIV program is based on the TB/DOTs program which is essentially be based on sputum smear for TB diagnosis. Based on national norms, it's critical to make available the capacity to perform chest Xray for TB diagnosis in the context of HIV/AIDS. The USG will use part of the PEPFAR resources to provide at least 20 major public institutions with necessary equipment and materials for chest Xray thru the MOH.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: The MOH will perform a needs assessment at the major public sites to make available and operational chest Xray equipment. This assessment will evaluate the needs for equipment, related commodities and materials as well as human resources capacity and operational costs

Activity 2 : Based on needs assessment, the MOH will procure and distribute necessary equipment and materials to at least 20 sites. Resources to support operational costs to provide training and ensure QA/QI and maintenance of the equipment will be provided to maintain quality of chest XRay.

Activity 3: The MOH will establish a referral system between the sites with XRay capacity and peripheral sites at each department to ensure that all eligible patients get access to this diagnosis capacity within the department.

Table 3.3.07:

Linked to Activities 9308, 9314, 9309, 9313, 9311, 9310, 9312.

SUMMARY: This activity will enable a network of 20 public health hospitals, already providing other HIV/AIDS services, to identify HIV/AIDS Orphans and Vulnerable Children (OVC) and provide these children and their families with a range of psycho-social support and basic clinical services in the absence of, or as a complement to, more structured OVC community-based programs. This activity will address a captive population which is largely represented by children of adult HIV/AIDS patients already attending these facilities; however, it will also be open to beneficiaries coming from other settings. The selected hospitals are expected to enroll 10,000 adult HIV infected patients, three-fourths of whom, based on empirical evidence, have at least one minor dependant. A total of 8,000 OVC will be targeted across the 20 sites. The program will ensure that a more systematic approach is adopted to identify OVC whose parents are already enrolled in care and provide the children with regular clinic-based services such as well-child visits, immunizations, growth monitoring, vitamin supplements, and rapid HIV-testing for infants born to infected mothers. The program will also be enhanced by the fact that the facilities already have direct contact with the parents and provide them with psycho-social support and education on issues related to the health and well-being of the children. The major emphasis of this activity is refurbishing of pediatric wards, human resources, training and commodity procurement, especially supplies. The targets are: orphans and vulnerable children, HIV-positive infants and children, HIV/AIDS affected families, and caregivers of OVC.

BACKGROUND: Five of the approximately 20 public hospitals in Haiti are currently receiving support from the President's Emergency Plan For AIDS Relief (PEPFAR) to develop HIV CT, PMTCT, palliative care, and anti-retroviral (ARV) services. Although care, treatment, and support for adults are well-established at these facilities, care for children is practically non-existent. Three of these hospitals will provide pediatric treatment in FY06; however, the focus remains too narrow to address the broader needs of children rendered vulnerable by the illness of one or both of their parents. Despite the fact that these hospitals cater to a large HIV/AIDS population (3000 patients currently, and 10,000 by the end of September 2008), few efforts are being made to identify and provide to the vulnerable children and dependants of these HIV/AIDS patients. The fledgling community-based programs are unable to rapidly expand their capacity to adequately meet the service needs of these OVC, and the hospitals are currently too overwhelmed by adult HIV/AIDS patients to take on that challenge. Most facilities are limited to one or two social workers whose schedules are completely filled with providing psycho-social support to patients undergoing treatment, and they receive limited support from community workers tracking patients who have missed clinic appointments. Furthermore, once an HIV-infected woman has delivered a baby, there is no structure in place to track the baby. If by chance the infant receives prophylactic treatment, there is no program in place to follow-up for HIV testing according to the established schedule, and no provision for documenting receipt of any other clinical services. Therefore, there is a critical need for the early identification of OVC, provision of basic services and effective referrals for wrap-around services.

ACTIVITIES AND RESULTS EXPECTED: Activity 1: Identification, tracking and specialized counseling for OVC. Under this activity, sites will recruit dedicated social workers and community workers, who will be responsible for encouraging patients to provide information on their dependants, visiting families and inquiring about their needs, encouraging and assisting patients in disclosing their status to their children and families, and providing appropriate advice to care-givers. The social worker will regularly visit all wards where testing and care services are provided to recruit clients. Particular attention will be given to the ante-natal clinic (ANC) and the maternity and the pediatric wards, which are currently not included in the care structure, in order to ensure that the program captures and enrolls vulnerable children at birth or when they receive medical attention. Under the supervision of social workers, the community workers will visit households to assess needs, monitor children's health, and provide hands-on continuous assistance to care-givers. Home-based testing may also be considered during these visits. The clinic-based OVC structure will provide linkages with other community-based OVC programs to ensure that the children and their families receive other wrap-around services. The funding for this activity will cover the recruitment of 1 social worker and 3 community health workers at each facility, along with the cost for the home visits.

Activity 2: Palliative Care to OVC. This activity will support a comprehensive package of services for OVC, including regular well-child-visits, immunizations, growth monitoring, de-worming, rapid testing of babies born to HIV-infected women, and vitamin supplements. The OVC community-based programs currently refer clients to hospitals and health centers for medical attention; however, these facilities have very few resources and limited capacity to provide services for these patients. With support under this activity, these hospitals can be strengthened to become part of an effective referral and counter-referral system with the community-based palliative care and OVC programs and serve their registered OVC with a comprehensive service package. The funding will support procurement of basic medical equipment and materials for the pediatric wards of these hospitals and increase their capacity to serve the children. Transportation costs for the visit to the clinics will be covered for those not living within walking distance of the clinic. Home-based care to sick children will be delivered through the community health workers.

Activity 3: OVC empowerment activities. Most of the facilities receiving support through this activity already have People living with HIV/AIDS (PLWHA) support activities with dedicated space and resources for introducing OVC issues and implementing discrete OVC support-group activities. This activity will target older OVC (i.e., 8 to 18 years) and engage them in creating support groups and conducting activities designed to build self-esteem. Staff implementing this activity will seek the advice and expertise of other organizations, such as the Bethel Clinic of the Salvation Army, which already have experience in this approach.

Activity 4: Training in collaboration with Partners in Health (PIH). PIH is conducting a very successful OVC program and has extensive experience in providing skill-based training in this area to social workers and community-health workers. MOH will use PIH's expertise to train personnel at public sites on providing OVC services as they have for training in other technical areas. The training curriculum will include: (i) community mobilization, (ii) individual and group counseling for children and families on OVC issues, (iii) children's nutrition and rights protection, and (iv) signs of medical complications experienced by infected children. Funding will cover the logistics for the sessions.

Linked to Activities 9308, 9314, 9309, 9313, 9311, 9310, 9312, 9362.

SUMMARY: The Ministry of Health (MOH) is the prime regulatory entity for health care service delivery in Haiti, including HIV services. It is also the most important provider of health services, with a network of dispensaries, community hospitals, regional departmental hospitals and a University Hospital. In FY 2006, many of these hospitals and health centers established counseling and testing (CT) services with USG support. Nineteen of the main public sites are receiving this support through a direct cooperative agreement (CoAg) with the MOH managed by an Executing Unit under the supervision of the central level. The supported sites include l'Hopital de l'Universite d'Etat d'Haiti (HUEH), the largest clinical facility and teaching center in Haiti, which has over 160,000 patient visits per year and 15 other departmental and communal hospitals that serve an average of 220,000 patients per year. From October 2005 to June 2006, this network tested 22,403 people and enrolled 3,000 patients into HIV care and treatment services. With FY 2007 resources, the USG plans to strengthen the capacity of the MOH to continue expanding CT services to patients seen at the hospital using a provider-oriented approach to optimize the potential for testing patients.

The MOH has attempted to institute a policy whereby CT is provided to all outpatients and inpatients in order to avoid missed opportunities to diagnose HIV. However, this policy has not been followed in a uniform manner due to lack of properly trained staff; inadequate organization of patient flow; and absence of educational activities within the facilities. While hospital patients constitute a captive population for counseling and testing, many missed opportunities continue to exist, and many facilities with the potential of doing CT have not yet introduced the service. Furthermore, training activities remain centralized. The lack of logistics for training at the local level has limited capacity to train personnel at all sites in counseling activities.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will provide field support to CT sites and CT services at existing and new sites will be integrated into the routine clinical services offered to all patients. Pre- and post-test counseling will be carried out at various wards of selected facilities, and test results communicated the same day. Funding will cover space remodeling to ensure that examination rooms guarantee confidentiality during counseling and that wards offer minimal room for testing activities; salaries of current counselors and phlebotomists and hiring of additional ones to guarantee continuous availability of services throughout business hours; and procurement of critical utilities such as gas for refrigerators.

Activity 2: The MOH will provide site and community-based HIV testing promotion to create demand and encourage patients to be tested. Funding will be centralized and will be used to procure equipment and materials for promotional activities (TV, VCR) for the sites; produce posters, brochures and other materials to be distributed to patients along with banners and street signs to create greater awareness of the opportunity offered by the facilities. Posters encouraging testing will be placed in prominent locations throughout the facilities. In addition, the MOH will support community testing days at all sites and will sponsor special radio spots promoting testing events.

Activity 3: The MOH will ensure that each service provider at the 25 participating sites develops the skills to provide pre- and post-test counseling and HIV testing using HIV rapid test kits. Training will include training for residents and continuing education sessions for the staff to keep them abreast of new developments in CT, particularly the psychological aspects of post-test counseling of HIV positive patients. This will include psychological support, assurance of confidentiality, identification of strategies to deal with family ramifications of the disease, including who in the family to discuss the patient's status with, organization of support groups, referral for nutritional support and other sources of economic support.

Activity 4: The MOH will reinforce regulatory activities and ensure adequate quality assurance and quality improvement (QA/QI) processes are in place. The USG Team will support the services of a national CT QA/QI team that will periodically visit all sites, use a supervision checklist, and ensure that all sites respect norms regarding CT. In addition, at this time, no clear effective policy is applied by CT service personnel in case of discordant results in couples. The USG will help the MOH integrate its facilities into a program that

will examine the best policies for counseling couples on discordant results.

Linked to Activities 9308, 8160, 9314, 10415, 9309, 9311, 9310, 9312, 9332, 9343, 10242.

SUMMARY: Through a cooperative agreement (CoAg) with the Ministry of Health (MOH), the United States Government (USG) team in Haiti will support the scale up of on-going ARV services at the State University Teaching Hospital (HUEH) and add four new major public sites: Sainte Therese Hospital in the Nippes Regional Department, Immaculee Conception Hospital and Jean Rabel Hospital in the North West Regional Department, and Isaie Jeanty Hospital (another University teaching hospital) in the West Department. The major focus of this activity will be to support the overall service organization at these sites to deliver quality treatment services. These resources will be integrated with those allocated through International Training and Education Center on HIV (I-TECH) to support technical assistance and clinical mentoring at the HUEH and Isaie Jeanty as well as with those allocated through the MOH to support CT, PMTCT and palliative care services at all five public sites. In addition, Isaie Jeanty and HUEH, as University Teaching Hospitals, will serve as venues to train interns and residents on HIV treatment. With these resources, the MOH will directly manage five of the forty-one anti-retroviral (ARV) sites which will be in place by the end of September 2008. The other thirty-five sites are being supported through Haitian Group for the Study of Kaposi's sarcoma and Opportunistic Infections (GHESKIO), Partners in Health (PIH), AIDS/Relief Consortium, the To Be Determined (TBD) United States Agency for International Development (USAID) Contractor and I-TECH.

BACKGROUND: Over the last three years the publicly-managed sites have increasingly become the major focus of the USG effort to expand clinical and ARV services. Most of these sites serve large and needy high-risk populations in the urban and metropolitan area. The major departmental hospitals have been supported through GHESKIO, PIH and, more recently AIDS/Relief, to deliver all clinic-based services (CT, PMTCT, clinical care and anti-retroviral treatment [ART]) in integration with other support from the Global Funds. Many deficiencies in these hospitals led to multiple challenges to the implementation of services at these public sites; however, the USG was able to allocate the necessary resources to make this approach successful. Recently, the USG began providing resources directly to the MOH to implement HIV services in the publicly managed sites. HUEH receives resources through a CoAg between the USG and the MOH to provide ARV services. Approximately ten additional public sites are receiving or will be receiving support through this CoAg to provide CT and palliative care services.

With FY07 resources, four of these ten palliative care sites will be upgraded to provide ARV services. One of them, Isaie Jeanty, is the largest maternity ward in the Port-au-Prince metropolitan area. This year, CT and PMTCT services will be integrated into care at Isaie Jeanty. It becomes critical to provide ARV services at this site to ensure a continuum of care for women and children served at this facility and also for the large needy population surrounding this hospital. Two of these ten sites, Sainte Therese and Immaculee Conception/Port-de-Paix hospitals, are departmental hospitals located in departments with the highest prevalence of HIV. A fourth site, Jean Rabel Hospital, is located in the very hard-to-reach North West Regional Department which is in need of more accessible ARV services. In addition, on-going services at HUEH will be expanded to reach 1,000 patients on ARV by the end of September.

MOH will get support through GHESKIO, I-TECH and CDC (see GHESKIO, I-TECH and CDC narratives) to support clinical mentoring, technical assistance and Quality Assurance/Quality Improvement (QA/QI) at the University teaching hospitals as well as at regional and local levels. Resources allocated will essentially support enhancement of infrastructure, hiring of clinical and community staff, operating costs and a team to coordinate and supervise activities.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will build on resources allocated for other program activities such as CT, PMTCT and Palliative care to enhance infrastructure, provide medical equipment and materials (including lab), hire additional clinical personnel (physicians, nurses, psychologists, counselors and social workers) and support additional community personnel to expand ARV services at HUEH and to implement these activities at the four other targeted public sites. The new personnel will be trained at GHESKIO and at PIH. Resources will be used to support the current

successful models of treatment which are based on high-quality clinical and lab assessments of patients to determine ARV eligibility; high-quality counseling and education of patients, family members and "accompagnateurs;" and on a high-quality pharmacy and community support plan to ensure adherence to treatment.

Activity 2: At the two teaching hospitals, HUEH and Isaie Jeanty, the MOH will build on resources available through I-TECH for clinical mentoring, training and technical assistance to reinforce the teaching of HIV treatment protocols for interns and residents. MOH will provide the resources to make available conference rooms, equipment and materials for teaching. Continuing education sessions will be held for the staff to keep them abreast of new developments in ART care relevant to their functions.

Activity 3: Strengthen referral linkages. In the different areas where the five MOH sites are located, there are a number of private and public hospitals offering voluntary counseling and testing (VCT) services. The MOH will establish a referral system between these peripheral sites and the ARV sites to ensure a continuum of care to patients. In addition, these ARV sites will be linked to the community-based-organizations (CBO) and People living with HIV/AIDS (PLWHA) support groups to provide integrated community support for patients enrolled in treatment.

Activity 4: At the MOH Central Office, a multidisciplinary team (clinician, counselor, social worker and lab technician) will be established to coordinate the program and to start building program capacity to perform QA/QI. This team will be trained and empowered by GHESKIO, I-TECH and CDC to play this role within the MOH sites. Over time, the team will progressively play a more national role. CDC will work with GHESKIO, PIH and I-TECH to ensure the availability of national standardized QA/QI tools for the treatment program (see CDC narrative for ARV services).

Linked to Activities 9308, 9314, 10415, 9313, 9310, 9312, 9923, 9283, 10353.

SUMMARY: The activities included in this project relate to building the laboratory infrastructure in Haiti through reinforcing the capacity of the National Public Health Laboratory (NPHL) and its national network. The FY07 funding will be used to maintain the infrastructure at the NPHL; continue the National QA/QC program through maintaining the External Quality Assistance Proficiency Testing (EQA PT) for HIV and establishing the EQA PT for Cluster of Differentiation 4 (CD4) enumeration; establish HIV antibody testing on dried blood spot at the NPHL is another component of the National QA/QC program; establish an Enzyme-Linked ImmunoSorbent Assay (ELISA)-based confirmatory testing at the NPHL in order to confirm and resolve discordant samples; establish a national laboratory training center at the NPHL; establish HIV pediatric testing and viral load capability at the NPHL; and train and hire laboratory personnel.

BACKGROUND: The capacity for laboratories to provide accurate test results is critical for public health. At present, Haiti is developing a functional regulatory body to determine laboratory performances in both the public and private sectors with support from the USG and other donors. The construction of a new NPHL was completed in August 2006 and is progressively being equipped, furnished, and made functional. The activities described here were funded by the USG in FY05 and FY06 and will be expanded in FY07 at the request of the Haitian MOH. Activities will be implemented directly by the NPHL employees with technical assistance from the USG Team, GHESKIO and other consultants. In FY 07, the USG has selected technical human resources specialized in critical laboratory areas to provide technical assistance to the NPHL to strengthening its capacity and increasing its functional activities.

ACTIVITES AND EXPECTED RESULTS: Activity 1: The NPHL will continue and expand the national QA/QC program. One hundred and fifty labs will participate in the EQA PT program for HIV testing including all 92 USG-supported labs and 58 private labs. In FY 07, the NPHL will continue its operation with its EQA PT program for HIV testing as well as start a new EQA PT for CD4 enumeration with assistance from the USG Team. For the HIV testing part, the NPHL will continue to procure panels from reliable sources and send them out throughout the country to 150 public and private laboratories to monitor and improve and ensure the reliability of testing results twice a year. The NPHL will request the laboratories or facilities that perform rapid HIV testing to prepare dried blood spots (DBS) from the samples they test and send them to the NPHL for QA/QC testing to ascertain the accuracy of the results delivered at the sites. The sites will be trained by GHESKIO and the NPHL staff in preparing, storage, and shipping the DBS specimens to the NPHL.

Activity 2: The NPHL will establish HIV antibody testing on DBS and blood specimens with technical assistance from GHESKIO to enable the NPHL to start assuming another role in lab QA/QC. This will supplement the QA/QC activity and support the evaluation of rapid HIV testing at the national level in Haiti. Additionally, an ELISA-based HIV antibody testing algorithm will be established as supplemental methods for confirming and resolving discordant results. All equipment needed for this activity has been procured using FY05 funding. The NPHL will receive test kits and lab supplies from the USG Haiti in FY 07.

Activity 3: NPHL will maintain and improve the infrastructure at the NPHL to maintain its crucial role as a national reference lab. To assume its role, the NPHL needs to maintain the physical structure of the building, ensure a continuous, reliable energy and water supply to the facility, and have reliable communication systems with its lab network. The NPHL will procure and install a 250 kilowatt generator, gas, a server, and two sets of inverters and batteries to ensure a constant electrical supply. The NPHL also will hire a facility maintenance engineer to operate the physical functions of the NPHL.

Activity 4: The NPHL will establish pediatric testing and viral load technology to build its capacity as the national reference laboratory. The NPHL is expected to provide the pediatric diagnosis services to the USG-supported facilities and to monitor patients receiving anti-retroviral (ARV). The USG will provide necessary laboratory equipment, test kits and supplies and short and long-term technical assistance for these activities.

Activity 5: The NPHL will train laboratory and healthcare personnel to support all program areas including PMTCT, VCT, TB/HIV integration, palliative care, ARV, pediatric diagnosis,

and viral load. The NPHL will work together with lab consultants to train 250 lab personnel at the national lab training center. Training modules in lab-related subjects will be developed by the consultants, and used throughout for trainings at the NPHL national lab training center.

Activity 6: The NPHL will determine baselines for CD4 and complete blood count (CBC). The NPHL will hire lab staff to conduct the analyses with technical assistance from the USG partners.

Activity 7: The NPHL will hire essential staff to carry out those activities outlined above. The NPHL has a severe shortage of staff. As the responsibilities and roles of the NPHL increase, it is crucial that the NPHL has sufficient number of technical staff to perform the expected tasks. The NPHL propose to hire a lab QA/QC coordinator, a EQA lab tech, three DBS and HIV ElLISAs QA/QC lab techs, a data lab manager, two specimens managing lab techs, three lab techs for pediatric diagnosis and viral load testing, and a NPHL facility maintenance engineer.

TARGETS: • 250 laboratory personnel trained in various laboratory testing and techniques • 350,000 persons receiving counseling and testing supported for QA/QC components of lab testing. • 97 sites supported to provide continuous QA/QC laboratory services to the PEPFAR program areas

Linked to Activities 9308, 8160, 9314, 10415, 9309, 9313, 9311, 9310, 9312, 9284, 9341, 9348.

SUMMARY: The purpose of this activity is to help realize the "three ones" concept by enabling the Ministry of Health (MOH) to: (i) finalize a consensual HIV/AIDS monitoring and evaluation (M&E) framework closely tied to the strategic objectives contained in the National Strategic Plan in accordance with the principle of "The Three Ones"; (ii) lead and validate the process of introducing new Health Management Information System (HMIS) and M&E mechanisms and tools into the system; (iii) supporting the production and distribution of standardized paper-based forms and registers developed for voluntary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT), palliative care and ARV to all 128 participating sites; (iv) assume a greater role in data validation and processing, as USG partners will be developing new mechanisms and transferring more of their responsibilities to the MOH; (v) reinforce its capacity for management and processing of data, as well as monitoring the performance of the different HIV/AIDS program areas; (vi) expand and maintain the information technology (IT) infrastructure that currently links the different levels of the system: the sites, the department level and the central level. The emphasis areas for this activity are: HMIS, IT, and HIV surveillance. The primary beneficiaries are the MOH officials and staff, donors, service providers, and sites' personnel.

BACKGROUND: Haiti's health care system is divided into three sectors: public facilities, accounting for about 40% of service delivery; private not-for-profit and mixed facilities and programs, accounting for another 40%; and private for-profit providers (medical clinics and hospitals) accounting for the remaining 20%. In addition to its role as service provider, the MOH governs and regulates the system through several central departments in charge of standards, supervision, quality control and strategic planning. Within the MOH, the units which play the most prominent role with regard to strategic information are: (i) the Unité de Coordination de la Lutte contre les IST/VIH/SIDA (UCC), responsible for planning, monitoring and oversight of all HIV activities in the country; (ii) the Department of Epidemiology (DELR), in charge of surveillance, control, regulation and integration of priority programs, including HIV/AIDS; and (iii) the departmental directorates, responsible for operations and oversight of field activities. Through a cooperative agreement (CoAg) with the MOH, funding has been provided by the President's Emergency Plan for AIDS Relief (PEPFAR) in FY05 and FY06 and has allowed: (i) greater access to data by the department and the central level through the electronic applications developed (Monitoring Evaluation Surveillance Interface [MESI] and the Electronic Medical Record [EMR]); (ii) the establishment of an infrastructure allowing regional and national hosting of data with possibility for replication, electronic transmission of data, and on-line assistance; (v) the revitalization of a case notification system at pilot sites that has paved the way for expanded surveillance activities; and (vi) an increase in the number the field visits carried out by the departments and the UCC.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will conduct consensus-building activities among all stakeholders (donors, MOH officials, and service providers) to develop a national health information system. To build consensus, the MOH will maintain and support the M&E cluster by calling regular cluster meetings, keep minutes of the meetings and provide adequate follow-up to all meeting points of discussion and validate the national M&E framework (currently in draft form) as well as a national M&E action plan. The MOH will organize a national M&E framework validation conference prior to the full implementation of the new system.

Activity 2: The MOH will continue to produce and distribute data collection and reporting tools and registers. Various tools have been designed or adapted for VCT, PMTCT and care, including a medical record. Most of these tools, developed with USG support, have been tested extensively in the field. The MOH will ensure seamless supplies to the sites.

Activity 3: The MOH will continue to expand and enhance IT infrastructure. With an objective to take advantage of IT and facilitate processing and sharing of information, PEPFAR and other donors have supported, through different mechanisms, the procurement and installation of IT equipment. The results have been remarkable. Monthly data are now available for 70% of implementing partners. In FY07 the efforts will concentrate on: (i) reaching out to the other 30% of partners not covered, (ii) sharing

existing IT resources within and between entities by providing hubs and network printers, (iii) protection of existing equipment by providing uninterrupted power supplies (UPS) where existing equipment is not protected, and (iv) additional basic computer training for field staff. Although the central unit of the Ministry will procure the equipment, the needs assessment and installation will be executed for the MOH by the CDC regional information officers (RIOs), who have specialized experience.

Activity 5: The MOH will participate in oversight of data processing and analysis and data quality control (QC) both at the central and departmental levels. The UCC will provide technical assistance to the departments to enable them to stay abreast of new quality assurance/quality control (QA/QC) concepts and methodologies. The departments will take on progressively more responsibilities for data validation and QA/QC at the sites and develop the capacity to perform site visits and data review. Mechanisms developed by SOLUTIONS, ITECH, TULANE University and MEASURE will be progressively transferred; and joint visits will be organized. MESI's electronic system has a built-in validation application which will allow the department to accept or reject reports from the sites after validation. Once trained on how to perform the verification of data, the departments will play an important role in data validation.

Activity 6: In collaboration with NASTAD, the DELR will take on full responsibility for the case notification system and will carry out some cross-border surveillance activities along the border with the Dominican Republic. The resources will support activities to be defined soon by the two countries.

Activity 7: The MOH will conduct regular program performance reviews. The USG Team will fund quarterly stakeholders meetings to review performance and discuss corrective actions in cases where performance is inadequate.

Linked to Activities 9308, 8160, 9314, 10415, 9309, 9313, 9311, 9310, 9312, 10370, 10240.

SUMMARY: This activity, which comes in direct support to the MOH and the National committee for HIV/AIDS is aimed at reinforcing the mechanisms for governance of the HIV/AIDS program in Haiti by reinforcing the National Committee for AIDS; strengthening the MOH's financial management and absorptive capacity; reinforcing the departmental level support to community activities by the management of 30 small competitive grants to community organizations, especially associations of People living with HIV/AIDS (PLWHAs). This activity, initiated in FY 2005 and pursued in FY2006, will expand in FY 2007 to include development of a national multi-sectoral council at the highest level to provide a coordinated response to the fight against HIV in Haiti, and hence, accomplish one objective of the "three ones" agenda. The major emphasis areas for that activity are local organization capacity development and training. The primary targeted populations are the country coordinating mechanisms, the MOH staff at central and departmental levels, the grass roots community-based organizations (CBOs), and PLWHAs.

BACKGROUND: Haiti's health care delivery system is divided into three sectors: public facilities, accounting for about 40% of service delivery; private not-for-profit and mixed public/private partnership facilities, accounting for another 40%; and private for-profit providers (medical clinics and hospitals), accounting for 20%. In addition, the MOH fulfills normative, regulatory and supervisory functions through different directorates established both at the central and the departmental levels.

Years of political instability have led donors to exclusively rely on emergency mechanisms to channel funding to Haiti. During the first two years of the President's Emergency Plan for HIV/AIDS Relief (PEPFAR), in the absence of mechanisms to directly fund the publicly-managed activities, support was channeled through USG private sector partners. While this approach allowed quick launching of activities, it was accompanied by high overhead costs that reduced funds available for field activities. With various funding streams linked to different program areas from PEPFAR, the United States Government (USG) established a CoAg with the MOH, which enabled the Ministry to develop a comprehensive program involving all levels (central, departmental and publicly managed sites). The program included field support for the development of CT, PMTCT, palliative care and ARV services at 20 of the major public hospitals of the country; the development of lab infrastructures throughout the country to support the biological monitoring of patients enrolled in services and the reinforcement of a national laboratory quality assurance/quality control (QA/QC) program; the reinforcement of a national monitoring and evaluation (M&E) system to monitor national HIV/AIDS program performance and results; the creation of small competitive grants under the leadership of the regional departmental directorates to foster and support local initiatives from community groups and local public agencies, taking advantage of the decentralized management at the departmental level; and the reinforcement of a policy environment suitable for the creation of a national response.

This activity has resulted in an increased capacity of the public sector to manage USG funds, thereby increasing the efficiency and efficacy of all interventions designed to prevent the spread of HIV, treat patients and provide palliative care and support services to PLWHAs and orphans and vulnerable children (OVC). In addition, participation of various sectors of the civil society has been enhanced through the increased channels of support to community activities and the reinforcement of governance of the program.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will reinforce its financial management capacity. The Executing Unit has successfully managed $2.2 million allocated through the USG CoAg in FY 2005 and has started the execution of the FY 2006 agreement. Money allocated to the unit has been spent within the limit allowed and in compliance with the USG standard provisions; and the overall targets set were reached successfully. With the possibility of doubling the targets and funding for FY 2007, capacity of the unit will be scaled up to match the increase in operations and oversight. The number of sites supported under the CoAg will grow from 19 to 25, and the number of departmental directorates will increase from 4 to 10. In addition, more central units within the MOH will be involved in program execution. The Executing Unit will be reinforced and its operation supported adequately to assist the 40 collaborating entities in planning,

execution, and reporting with an emphasis on internal financial control with regular internal audits at supported sites.

Activity 2: The MOH will continue to reinforce grant and financial management capacity at the regional level. This activity, which was initiated successfully in FY05 in 4 departments and which has supported funding of several PLWHA-led activities, will be expanded in FY07 to all 10 regional departments. Each department will manage a grant portfolio of $25,000. These grants will finance a menu of activities proposed exclusively by local community groups or local administrative entities, with priority to PLWHA organizations. Those activities may include, but are not limited to: awareness and educational activities; community care or home-based care initiatives; community day-care centers for OVC. The regional department directorates will ensure the promotion of this grant facility; interface with local organizations; facilitate the review of proposals by the regional committees to be put in place; administer the grants; and oversee the execution of activities by awardees. A total of 30 local organizations are expected to participate in this initiative. They will receive technical assistance and support from both the Executing Unit and the departmental directorates for the management of their awards.

Activity 3: The MOH will continue the process of establishing the National Committee for HIV/AIDS. Funding was set aside in FY 2006 to begin the process, and in FY2007, multi-sector participation will be addressed at a broader policy level and will be institutionalized through the formal and legal creation of a National Committee for HIV/AIDS. The functions of the National Committee will include: follow-up and periodic revision of the HIV/AIDS strategy and action plan; development of a national scale-up plan for universal access to HIV/AIDS prevention, care and treatment; formulation of policies related to HIV/AIDS; approval of large projects with a national scope; elaboration of a national HIV/AIDS progress report that at the end of each year; and advocacy for HIV/AIDS. The National HIV/AIDS Committee will receive support to create advocacy activities among the constituencies of other sectors; develop functioning sub-committees; and acquire dedicated secretarial services.