Linked to Activities 9318.9673,10668,9363,10241, 9725, 9674

SUMMARY: The activities described below are carried out to provide comprehensive PMTCT services to the HIV-infected women served by the nine sites of PIH and its local partner, Zanmi Lasante (ZL). These PMTCT activities will be conducted within PIH/ZL's "four pillars" model for a comprehensive HIV program in the context of primary care, which involves: HIV prevention and care, including voluntary counseling and testing (VCT); identification and treatment of tuberculosis (TB) and other opportunistic infections (OIs); sexually transmitted infection (STI) detection and treatment; and women's health and PMTCT services. The primary emphasis areas for these activities are human resources, infrastructure, training and food/nutrition support. The primary target population for these services is HIV-infected pregnant women. The activities will be carried out at seven sites in the Central Regional Department of Haiti and two sites in the Artibonite Regional Department.

BACKGROUND: PIH/ZL's PMTCT treatment activities are part of a comprehensive HIV prevention and treatment program started by Partners In Health and its Haitian-based sister organization, Zanmi Lasante (PIH/ZL) in 1998; expanded in late 2002 though the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria; and further expanded to Hinche, Cerca La Source, Petite Rivière and St. Marc with the support of USG-PEPFAR in FY05 and FY06. Since 2004 the program has been a collaboration between these four important partners—PIH/ZL, MOH, Global Fund, and PEPFAR—and in 2005 work in the Artibonite region has been strengthened by involving several new nongovernmental organization (NGO) partners in the community of St. Marc - Sant Santé Premye Echelon (SSPE) and Promotion Objectif Zerosida (POZ) - and in Petite Rivière, Centre Medical Charles Colimon (CMCC), a Medecins Sans Frontières-affiliated institution. PIH/ZL's PMTCT programs began in the mid-1990s, soon after a study showed that antiretroviral treatment (ART) reduced mother-to-child HIV transmission (MTCT). Since then, PMTCT activities have been a central component of PIH/ZL's HIV Equity Initiative, with hundreds of HIV-infected pregnant women enrolled. With a significant grant from the USAID child survival program, PIH/ZL is currently strengthening and broadening its maternal and child health programs based both in the community and at its clinics across the Central Plateau, in particular expanding and strengthening the network of ajan fanm (community health workers trained in women's health) and traditional birth attendants (TBAs). In all PMTCT activities, PIH/ZL is committed to a long-term partnership with MOH and to strengthening the public sector by training local staff, including MOH health workers.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: PIH/ZL will provide counseling and testing (CT) for pregnant women. As part of the PIH provider-initiated, or "opt-out," testing method, pregnant women seen at all nine sites receive counseling and are offered HIV testing during a routine prenatal visit, reducing perceived stigma as HIV testing is not the primary cause for entrance to health facilities or the laboratory. PIH/ZL enlists ajan fanm to increase referrals of pregnant women to clinics for this initial testing and prevention education. This funding will support the staff and infrastructure necessary to provide VCT to pregnant women in the context of primary and prenatal care.

Activity 2: PIH/ZL will provide prenatal, perinatal, and postnatal care to HIV-infected pregnant women at each of PIH/ZL's nine sites. In the prenatal period pregnant women are enrolled in the PMTCT program and receive counseling and education on the ways HIV is transmitted to infants and the ways transmission can be prevented. ART is offered to women with advanced HIV infection and to all women in the third trimester of pregnancy to reduce the risk of HIV transmission. Nutritional and dietary advice, as well as nutritional supplements, multi-vitamins, and STI screening and treatment are also routinely provided. Mothers and infants receive comprehensive postnatal care involving ART for the infant, ongoing ART for the mother (if required based on her stage of disease), education, and increased nutritional and home-based support to enable formula feeding for those women who choose not to breast feed. Infants are followed monthly by the clinical and community team until the infant reaches 18 months of age. Funding will support the PMTCT program with the addition of several clinical professionals, including two doctors and 12 nurses, and will allow for the on-going training of clinicians in the detection and treatment of pregnant women at risk for transmitting HIV.

Activity 3: PIH/ZL will provide social support to all HIV-infected women enrolled in a PMTCT program. Throughout each phase of the PMTCT program, each pregnant woman is supported by an accompagnateur who visits her in her home once or twice a day to perform needs-assessment, as well as to assist with ART adherence and other clinical care. During clinic visits, PMTCT program patients receive education and nutritional support to decrease the likelihood of transmission of HIV to infants during or following delivery. Following delivery, new mothers receive nutritional supplementation as well as infant formula and supplies for preparation of clean water. Support groups, accompaniment, and medical supervision and care account for a rate of MTCT within PIH/ZL's program that is less than 2%. Funding will ensure the continued success of PIH/ZL's PMTCT programs by supporting the hire of over 100 additional accompagnateurs, and by supporting the on-going training of all PIH/ZL accompagnateurs and ajan fanm.

These PMTCT activities increase gender equity by supporting efforts to reach and treat an equitable number of HIV-infected women and men, and by increasing access to information, services and care for women and girls. These activities contribute to the PEPFAR goals by improving access to HIV testing and treatment, enrolling individuals on ART, and preventing the transmission of HIV to HIV-negative infants.

Linked to Activities 9682, 9673, 10668, 9363, 10241, 9333, 9314.

SUMMARY: The activities described below are designed to optimize quality of life for HIV-infected patients and their families. Palliative care will be conducted within PIH/ZL's "four pillars" model for implementing a comprehensive HIV program in the context of primary care, which involves: 1) HIV prevention and care, including voluntary counseling and testing (VCT); 2) Identification and treatment of TB and other opportunistic infections (OIs); 3) Sexually transmitted infection (STI) detection and treatment; and 4) Women's health and prevention of mother-to-child transmission (PMTCT) services. The primary emphasis areas for palliative activities are human resources, infrastructure, training, and food/nutrition support. The primary target population for palliative care is people living with HIV/AIDS. The activities will be carried out at seven sites in the Central Department of Haiti (Belladère, Boucan Carré, Cange, Cerca La Source, Hinche, Lascahobas, Thomonde), two sites in the Artibonite Department (Petite Rivière and St. Marc), and an undetermined site along the Haiti/Dominican Republic border.

BACKGROUND: PIH/ZL's palliative care activities are part of a comprehensive HIV prevention and treatment program started by Partners In Health and its Haitian-based sister organization, Zanmi Lasante (PIH/ZL) in 1998; expanded in late 2002 through the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria; and further expanded to Hinche, Cerca La Source, Petite Rivière and St. Marc with the support of the President's Emergency Plan for AIDS Relief (PEPFAR) in the Country Operational Plan (COP) 05 and 06. Since 2004 the program has been a collaboration between these four important partners—PIH/ZL, MOH, Global Fund, and PEPFAR—and since 2005 work in the Artibonite region has been strengthened by involving several new Non-Governmental Organization (NGO) partners in the community of St. Marc - Sant Santé Premye Echelon (SSPE) and Promotion Objectif Zerosida (POZ) - and in Petite Rivière, Centre Medical Charles Colimon (CMCC), a Medecins Sans Frontières-affiliated institution. PIH/ZL is committed to a long-term partnership with MOH, and in all of the described activities, PIH/ZL is dedicated to strengthening the public sector by training local staff, including MOH health workers.

For a decade, the PIH/ZL palliative care activities have been delivered by supplementing a high standard of clinical care with a strong community-based network of trained patient advocates. All patients are seen daily in their homes by the advocates, as part of ARV services, but these visits also serve as an intervention to monitor outcomes and provide palliative services. If patients experience side effects, advanced disease, or other barriers to outcomes, the advocates address the situation either directly or with a referral to a clinic. If the advocates see other health problems developing in the household, such as the sudden weight loss of a family member, they will bring that individual in for treatment.

ACTIVITES AND EXPECTED RESULTS: Activity 1: General Clinical Care. The first activity is to provide general clinical care for the HIV-infected adults and children and their families served at all 9 PIH/ZL sites. This care, both in-patient in health clinics and out-patient in mobile clinics and home visits, includes primary care, women's health services, detection and treatment of sexually transmitted infections, detection and treatment of tuberculosis (described in Activity Narrative on Palliative Care: TB/HIV), prophylaxis and treatment for opportunistic infections, and clinical monitoring of patients infected with HIV (including Hematocrit levels, electrolytes, liver function tests and Cluster of Differentiation 4 [CD4] counts). This funding will support the necessary infrastructure and human resources for providing these clinical services to an increased number of HIV-infected patients, including the hiring of 16 additional clinical staff, 10 additional laboratory and pharmacy staff, and 20 administrative and logistical support staff. These funds will also support the on-going training of the clinical staff in effective palliative care strategies.

Activity 2: Patient Advocate Employment and Training. The second activity is the employment and training PIH/ZL's patient advocates. In 2007, over 100 new advocates will be hired, and 45 advocates will be promoted into the position of advocate supervisors. In monitoring and supporting PIH/ZL's HIV patients, PIH/ZL's 1,245 community health care workers form the backbone of the HIV Equity Initiative. Funding will be used to provide advocates with on-going trainings in the delivery of palliative care, both at PIH's health centers in the Central Department and in the relatively new clinics in the Artibonite.

Moreover, new and selected community health care workers will participate in more formal classroom-based trainings and clinical and community-based practicum that address palliative care for HIV-infected individuals and their families.

Activity 3: Social and Psychological Support. The third activity will provide social and psychological support to at least 3,500 HIV patients (roughly one-third of all HIV-positive patients being followed at ZL sites) and their families based on needs assessments conducted by program physicians and social workers. This support includes monthly patient meetings, support groups, and individual psychosocial support for those who cannot benefit from group activities (specifically those individuals who have not disclosed their HIV status). This program will be strengthened in 2007 with the hiring of 2 additional social workers to support HIV-infected patients in the Central Plateau and Artibonite regions.

Activity 4: Financial Assistance for Transportation. The fourth activity will provide financial support to at least 3,000 HIV patients (roughly one-third of all HIV-infected patients being followed at ZL sites) and their families. This support includes the following: assistance with school fees, housing assistance, and food support, as well as financial assistance for transportation to/from the hospital.

These palliative care activities mitigate the burden of care on women and girls by linking care programs with resources such as psychosocial support groups and assistance with the provision of school fees, food and transportation. In paying school fees, we are also ensuring that children and adolescents, especially girls, are able to remain in school. All palliative care activities and results contribute to the PEPFAR 2-7-10 goals by providing comprehensive care to HIV-infected individuals.

Linked to Activities 9672, 9675.

SUMMARY: Tuberculosis (TB) is the most common and deadly opportunistic infection in Haiti and remains rampant among HIV-positive patients and their families due to chronic malnutrition, HIV, and overcrowded living conditions. The activities described below are carried out to strengthen and expand the capacity of PIH and its local partner organization Zanmi Lasante (ZL), to perform TB cultures for HIV-positive patients, and ultimately to prevent and treat TB infection. TB prevention and treatment activities will be conducted within PIH/ZL's "four pillars" model for implementing a comprehensive HIV program in the context of primary care, which involves: HIV prevention and care, including voluntary counseling and testing (VCT); Identification and treatment of TB and other opportunistic infections (OIs); sexually transmitted infection (STI) detection and treatment; and women's health and prevention of mother-to-child transmission (PMTCT) services.

BACKGROUND: PIH/ZL's TB prevention and treatment activities date back to the work of community health workers (CHWs) in the early 1980s. Experience with directly observed therapy (DOT) in the context of TB treatment was instrumental to the design of PIH/ZL's HIV treatment program. TB activities have now been fully integrated into the comprehensive HIV prevention and treatment program started by PIH/ZL in 1998; expanded in late 2002 through the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and further expanded to Hinche, Cerca La Source, Petite Rivière and St. Marc with the support of PEPFAR in FY05 and FY06. Since 2004 the program has been a collaborative between these four important partners—PIH/ZL, MOH, Global Fund, and President's Emergency Plan for AIDS Relief (PEPFAR)—and since 2005 work in the Artibonite region has been strengthened by involving several new nongovernmental (NGO) local partners. PIH/ZL is committed to a long-term partnership with the MOH, and in all of the activities described; PIH/ZL is dedicated to strengthening the public sector by training local staff, including MOH workers.

ACTIVITES AND EXPECTED RESULTS: Activity 1: PIH/ZL will provide services to detect, treat, and prevent TB among the HIV-infected individuals served by its nine sites. As HIV treatment in the context of primary care is delivered at an increasing number of sites and locations, strengthening and expanding PIH/ZL's capacity to prevent, detect and treat TB/HIV co-infection will be essential to the success of our patients. Additional clinical human resources supported by this funding (including two doctors, 12 nurses and three pharmacy staff) will allow for greater clinical and programmatic focus on this essential component of HIV care. Funding will also support TB/HIV-related laboratory capacity, and the maintenance of infrastructure required for TB prophylaxis, detection and treatment at each of PIH/ZL's nine sites.

Activity 2: PIH/ZL will train providers in the prevention and/or treatment of TB for HIV-infected individuals. All clinicians and accompagnateurs will receive training on the management of TB/HIV co-infection in regularly held meetings. Moreover, selected clinicians and community health workers from all PIH/ZL sites will participate in more formal classroom-based trainings and clinical and community-based practicum that address TB identification, treatment and prophylaxis strategies for HIV-infected individuals.

Activity 3: PIH/ZL will provide HIV counseling and testing services to all TB patients at its nine sites and will provide TB prophylaxis to all eligible HIV positive patients.

As with all PIH/ZL palliative care, the above activities strive to ensure that an equitable number of women and men receive treatment. In improving the health of HIV-infected patients, we strive to enable their full participation in society at every level and to reduce the stigma and discrimination associated with HIV status. The above activities and results contribute to the PEPFAR 2-7-10 goals by providing comprehensive care to HIV-positive individuals.

1800 TB patients tested for HIV

Linked to Activities 9682, 9318, 9673, 9363, 10241.

SUMMARY: Activities are carried out to support orphans and vulnerable children (OVC) through four components: reinforcing existing primary/ambulatory care to increase capacity for identification of children infected or affected by HIV; providing nutritional support; providing psychosocial support; and providing social assistance. These activities will be conducted within PIH/ZL's "four pillars" model for implementing a comprehensive HIV program in the context of primary care, which involves: HIV prevention and care, including voluntary counseling and testing (VCT); identification and treatment of tuberculosis (TB) and other opportunistic infections (OIs); sexually transmitted infection (STI) detection and treatment; and women's health and prevention of mother-to-child HIV transmission (PMTCT) services. The primary emphasis areas for these activities are food/nutrition support and community mobilization/participation. Specific target populations include OVC, caregivers of OVC, and HIV/AIDS-affected families. The activities will be carried out at seven sites in the Central Regional Department, and two sites in the Artibonite Regional Department.

BACKGROUND: PIH/ZL's OVC activities are part of a comprehensive HIV prevention and treatment program started by PIH/ZL in 1998; expanded in late 2002 through the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and further expanded with the support of USG PEPFAR funding in FY05 and FY06. Since 2004 the program has been a collaborative between these four important partners—PIH/ZL, MOH, Global Fund, and President's Emergency Plan for AIDS Relief (PEPFAR)—and since 2005 work in the Artibonite region has been strengthened by involving several new nongovernmental organization (NGO) partners in the community of St. Marc - Sant Santé Premye Echelon (SSPE) and Promotion Objectif Zerosida (POZ) - and in Petite Rivière, Centre Medical Charles Colimon (CMCC), a Medecins Sans Frontières-affiliated institution. Though PIH/ZL has provided social assistance to vulnerable and HIV-affected children since its inception, in 2004 PIH/ZL officially launched its Program on Social and Economic Rights for HIV-infected patients and their families. Similarly, educational assistance to OVC has been a component of the PIH/ZL project for over a decade; and in 2005 the program was expanded to encompass school fee assistance and formalized documentation and long-term follow-up for this project. With a significant grant from the United States Agency for International Development (USAID) child survival program, PIH/ZL is currently strengthening and broadening its maternal and child health programs based both in the community and at its clinics across the Central Regional Department. In OVC activities, PIH/ZL is committed to a long-term partnership with the MOH and to strengthening the public sector by training local staff, including MOH health workers.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: Based on national population statistics, the total population of children in Haiti is estimated to be 227,000. Fifteen percent of Haitian children are believed to be orphans, as described by the USAID/ United Nations Children's Fund (UNICEF) document Children on the Brink, 2004; this estimate suggests that PIH/ZL serves an area containing approximately 34,000 children who have lost one or both parents. Throughout the Central Plateau there are thousands more vulnerable children; those whose parents are currently HIV positive, or those who have family members affected by the illness. The first activity is to reinforce primary and ambulatory care for children to increase capacity for identification of children infected and affected by HIV, including promotion of vaccination and well-child visits. This will be done in the context of comprehensive care that is currently provided at each of our nine sites throughout Haiti. This funding will support the personnel, equipment and infrastructure demanded to serve an increasing number of OVC, as well as related laboratory equipment.

Activity 2: The second activity is to support social workers and accompagnateurs in evaluating the needs of HIV affected children and their families to reduce the risk of malnutrition. Identification of children at risk will be strengthened by the training of accompagnateurs to determine children who may require nutritional supplementation. Accompagnateurs will also ensure adequate follow up and growth monitoring of children at risk to prevent relapse. This activity will enhance ZL's nutritional assistance program, in which we currently support 3,000 children per year. We will also develop a mechanism for

distribution of food supplements to children at risk and will expand upon our canteen feeding program at severely under-resourced schools, to ensure that vulnerable children are receiving one meal per day while at school.

Activity 3: The third activity is to provide psychosocial support to OVC through the employment and training of social workers. The social workers will offer psychosocial support groups to children affected by HIV and their HIV-positive parents as a means of helping to develop coping strategies. Moreover, the social workers will promote a prevention curriculum as a means of reducing the chances of OVC from becoming HIV-infected themselves. The social workers will also provide individual psychosocial support for those who cannot benefit from group activities (specifically those individuals/parents who have not disclosed their HIV status). This funding, in addition to supporting the human resources and infrastructure required of the OVC program, will provide salary support for two additional social workers to support work throughout the Central Plateau and the expansion to the Artibonite region.

Activity 4: The fourth activity is to provide social assistance to orphans and their families, as well as school fees to encourage children to attend school. This funding will provide 3,000 scholarships of $50 each to children of HIV-positive parents per year, expanding upon the social assistance provided by PIH/ZL in past years.

These OVC activities address gender issues by mitigating the burden of care on women and girls by linking care programs with resources such as psychosocial support groups, the school canteen program, provision of school fees and food. In paying school fees, we are ensuring that children and adolescents, especially girls, are able to remain in school. The provision of food and educational assistance are wraparound activities for PIH/ZL, as we have partnered with the United Nations World Food Program and private funders in these projects.

70 OVC referred to an HIV Treatment Program

Linked to Activities 9682, 9318, 9673, 10668, 10241.

SUMMARY: The activities described below are carried out to support comprehensive counseling and testing services, and to ensure training and supervision of trainers/counselors in counseling and testing (CT) and sexually transmitted infection (STI) detection and management. The primary emphasis areas for these activities are human resources, training and infrastructure. Specific target populations include adults, most-at-risk populations, out-of-school youth, street youth, migrants, orphans and vulnerable children (OVC) and people living with HIV/AIDS (PLWHA). The activities will be carried out at seven sites in the Central Regional Department, and two sites in the Artibonite Regional Department.

BACKGROUND: PIH and its local partner organization, Zanmi Lasante (ZL)'s CT activities are part of a comprehensive HIV prevention and treatment program started by PIH/ZL in 1998; expanded in late 2002 through the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and further expanded to Hinche, Cerca La Source, Petite Rivière and St. Marc with the support of President's Emergency Plan for AIDS Relief (PEPFAR) in FY05 and FY06. Since 2004 the program has been a collaboration between these four important partners—PIH/ZL, MOH, Global Fund, and PEPFAR—and since 2005 work in the Artibonite region has been strengthened by involving several new nongovernmental organization (NGO) partners in the community of St. Marc - Sant Santé Premye Echelon (SSPE) and Promotion Objectif Zerosida (POZ) - and in Petite Rivière, Centre Medical Charles Colimon (CMCC), a Medecins Sans Frontières-affiliated institution. PIH/ZL is committed to a long-term partnership with the MOH, and in all of the activities, PIH/ZL is dedicated to strengthening the public sector by training local staff, including MOH health workers.

One of the most daunting challenges facing HIV scale up efforts in poor, rural settings is the question of case detection: identifying HIV-positive people for enrollment in treatment. Because the public sector has a meager budget and is able to provide little in the way of primary health care services, many of the public clinics in Haiti stand empty. In this context, there is little uptake of CT. Without reinforcing primary health care or integrating HIV casefinding and treatment within expanded services, initial efforts to find HIV cases will be unsuccessful. For example, freestanding voluntary counseling and testing (VCT) was initiated in the capital of the Central Regional Department, Hinche, by the MOH in January 2003; in the first year of operation, only 43 patients were tested. The PEPFAR-backed PIH/ZL initiative in Hinche began in March 2004. In the first year of joint operations, the PIH/ZL-MOH clinic in Hinche performed 5,884 tests; of these, 435 were positive, and 310 people were started on antiretroviral treatment (ART).

The comprehensive services that have needed reinforcement at each of the HIV sites include offering CT via the "opt-out" strategy in the primary care clinic; improved TB casefinding and holding; the diagnosis and treatment of STIs; and expanded women's health services. These "four pillars" provide the basic entry points for the ART program and assure improved health in the community at large. Results of the activities described below will contribute to the PEPFAR 2-7-10 goals by improving access to and quality of CT services in order to identify HIV-positive persons and increase the number of persons receiving ART services.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The first activity is to continue providing comprehensive CT services via the "opt-out" strategy in the primary care clinics at PIH/ZL's six hospitals/health centers in the Central Plateau, as well as in the areas around these sites via mobile clinics. This activity will build on last year's success in reaching just over 45,000 individuals with CT. With this renewed funding, PIH/ZL will increase and improve efforts to provide CT to Haiti's most marginalized groups, including migrants and OVC. In order to reach these high risk groups, we will with this funding initiate a series of activities, including additional mobile clinics, a site-wide community outreach campaign for uptake of CT, and greater programmatic and staff focus on identifying and treating pediatric HIV cases (including Dried Blood Spot [DBS] testing for all OVC less than 18 months of age). In these activities, PIH/ZL will strive to ensure that an equitable number of women and men receive treatment. New CT staff will be trained in coordination with the USG-supported I-TECH/INHSAC training program in CT.

Activity 2: The second activity is to scale-up access to CT in the Artibonite region. PIH/ZL will expand CT services within a primary care setting at the public health centers at Petite Riviere, St. Marc and Montrouis. This expansion will necessitate training of clinicians at these new sites in CT practice, as well as require the enhancement of facilities for CT activity.

Activity 3: The third activity is the detection and treatment of STI. Through this activity PIH/ZL will maintain the infrastructure to detect and manage syphilis and other STIs within the HIV initiative at its six sites in the Central Plateau and will grow this capacity at the health centers at Petite Riviere, St. Marc and Montrouis. This latter effort will require training of the clinical staff (both ZL and MOH employees) at these newer sites to ensure effective STI detection and treatment.

Linked to Activities 96829318, 9673, 10668, 9363, 9313, 9282.

SUMMARY: The activities described below are carried out to maintain access to antiretroviral therapy (ART) for existing patients and expand access to ARV services to additional HIV-infected people in the Central and Artibonite Regional Departments of Haiti. These ART activities will be conducted within Partners in Health/Zanmi LaSante (PIH/ZL)'s "four pillars" model for implementing a comprehensive HIV program in the context of primary care, which involves: 1) HIV prevention and care, including voluntary counseling and testing (VCT); 2) Identification and treatment of TB and other opportunistic infections (OIs); 3) Sexually-transmitted infection (STI) detection and treatment; and 4) Women's health and PMTCT services. The primary emphasis areas for these ARV activities proposed are human resources, infrastructure, training, and quality assurance (QA) and supportive supervision. The primary target populations for these ARV services are people living with HIV/AIDS (PLWHAs), including HIV positive infants and children. The activities will be carried out at seven sites in the Central Department of Haiti (Belladère, Boucan Carré, Cange, Cerca La Source, Hinche, Lascahobas, Thomonde), and two sites in the Artibonite Department (Petite Rivière and St. Marc).

BACKGROUND: PIH/ZL's ARV treatment activities are part of a comprehensive HIV prevention and treatment program started by PIH/ZL in 1998; expanded in late 2002 through the public sector in partnership with the Haitian Ministry of Public Health and Population (MOH) and with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); and further expanded to Hinche, Cerca La Source, Petite Rivière and St. Marc with the support of President's Emergency Plan for AIDS Relief (PEPFAR) in the Country Operational Plan (COP) 05 and 06. Since 2004 the program has been a collaborative between these four important partners—PIH/ZL, MOH, Global Fund, and PEPFAR—and since 2005 work in the Artibonite region has been strengthened by involving several new non-governmental (NGO) partners in the community of St. Marc - Sant Santé Premye Echelon (SSPE) and Promotion Objectif Zerosida (POZ) - and in Petite Rivière, Centre Medical Charles Colimon (CMCC), a Medecins Sans Frontières-affiliated institution. PIH/ZL is committed to a long-term partnership with MOH, and in all of the activities described, PIH/ZL is dedicated to strengthening the public sector by training local staff, including MOH health workers. As of July of 2006, PIH/ZL has more than 2200 patients on ART and is actively expanding to bring direct services to the Artibonite sites.

ACTIVITES AND EXPECTED RESULTS: Activity 1: Patient Maintenance: The first activity is to maintain individuals currently on ART by improving program retention and enhancing clinical follow-up. By April 2007, PIH/ZL will have scaled-up services in the upper region of the Central Department (Cerca La Source and its surrounding health centers), and in St. Marc and Petite Riviere. Funding will be used to employ 1200 accompagnateurs and 45 accompagnateur supervisors, and to support monthly trainings of these accompagnateurs, ensuring a strong network of community health workers comprehensively trained in ARV management and adherence strategies. Funding will also support ARV-related laboratory capacity and the infrastructure required for ARV service delivery at each of PIH/ZL's nine sites.

Activity 2: Case Detection and Enrollment: As PIH/ZL will begin providing comprehensive HIV care in several new locations in 2006 and 2007, and will aggressively seek increased enrollment from the Central Plateau's most marginalized and high risk groups, the second activity is to enroll additional patients on ARV. In order to ensure that quality ARV services are delivered to this increasing number of HIV+ patients, PIH/ZL will expand staff resources with several new hires, including 2 doctors, 12 nurses, 3 pharmacy staff, 45 accompagnateur supervisors, and roughly 100 additional accompagnateurs. This funding will be used to provide comprehensive and on-going training of clinical staff and accompagnateurs both at PIH/ZL's health centers in the Central Department and in the relatively new clinics in the Artibonite. Clinicians and community health workers from all PIH/ZL sites will participate in a three-tiered training approach: a) classroom-based training in Cange and Hinche focusing on ARV service delivery, b) clinical practicum (observation of HIV care in already established PIH/ZL HIV care clinics) focusing on management of patients newly started on ARV; and c) community-based practicum (observing Directly Observed Therapy [DOT]) focusing on adherence strategies.

These above activities will contribute to the PEPFAR 2-7-10 goals by increasing the number of individuals on ARV treatment.