Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 5146
Country/Region: Haiti
Year: 2007
Main Partner: Management Sciences for Health
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $4,745,000

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $655,000

Linked to Activities 9791,9937,10109,9676,9365,10203, 9674, 9725.

SUMMARY: PMTCT is an integral part of comprehensive HIV care and treatment of people living with HIV/AIDS (PLWHA). Activities described in this narrative will be conducted in 19 non-governmental organization (NGO) sites that will operate under the USAID contractor to be selected to manage the NGO umbrella mechanism in collaboration with the Ministry of Health (MOH). PMTCT training activities will be conducted in collaboration with the Ministry of Health (MOH), the Haitian Institute for Community Health (INHSAC) through I-TECH and the John Hopkins Program for International Education and Gynecology Obstetric (JHPIEGO). At the community level, activities will target traditional birth attendants (TBAs), community health workers (CHWs), and couples expecting children. Pregnant women and their partners will be encouraged to attend antenatal clinics (ANC) through community mobilization activities.

BACKGROUND: Although the current USAID contract for the management of the NGO umbrella mechanism with Management Sciences for Health will end in September 2007, steps have already been taken to put in place a follow-on program that will be operational by mid 2007, and FY 2007 PEPFAR funding will be put into this mechanism. A new USAID contractor will have been identified by that time through which resources to support PMTCT services in the NGO network will be channeled. Facility-based PMTCT already exists at the 19 sites covered in this activity but there is no significant work at the community level to ensure that all pregnant women are encouraged to be tested for HIV and accompanied to CT centers and that women enrolled in the PMTCT program follow up with their pregnancy and birth plan.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: The USAID contractor 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 USAID contractor 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, 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, HIV-positive mothers and their babies will be referred to HAART centers for clinical care follow-up. The program will ensure that female healthcare providers are equitably represented in all trainings and in the implemetation of activities.

Activity 2: Program retention of HIV-positive pregnant women will be improved by ensuring the cost of hospital visits and hospital delivery are covered, including transportation to the hospital. The NGO PMTCT sites will work closely with their network of community health agents and traditional birth attendants (TBA) to carry out a tracking system for the enrolled pregnant women. Most of the NGOs work closely with community Mothers Clubs that will be engaged to help ensure that all pregnant women are tested for HIV

Activity 3: The USAID contractor 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 and will organize community testing days, on patron saints days, and on special days (i.e. International AIDS Day, Candlelight Vigil Day, etc.). Promotional activities such as public service announcements within the targeted communities, banners and street signs will make the population, and particularly pregnant women, aware of this opportunity. HIV positive pregnant women will be encouraged to join PLWHA support groups where they will have access to micro-credit programs for income generation and productive actvity creation and interventions against violence and coercion.

Activity 4: The USAID contractor will provide continuing education sessions for staff to keep them abreast of new developments in PMTCT, particularly the psychological aspects of post-test counseling of HIV-positive pregnant women. In collaboration with JHPIEGO and I-TECH/INHSAC training sessions, will be held onsite to ensure participation of the personnel.

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $100,000

Need to input narrative and targets

Table 3.3.02: Program Planning Overview Program Area: Abstinence and Be Faithful Programs Budget Code: HVAB Program Area Code: 02 Total Planned Funding for Program Area: $ 4,046,983.00

Program Area Context:

Historically, Haiti has had the most severe epidemic in the LAC region. The 06 UNAIDS Report on the Global AIDS Epidemic puts the prevalence at 3.8%. Haiti's epidemic is best defined as "mixed" for while the epidemic is likely being driven by most-at-risk populations such as commercial sex workers, many new infections are also caused by the sexual activity of mobile working men and youth 15-24 years old, especially out-of-school youth engaging in transactional sex. In the 1980s, the male to female HIV ratio was 4:1 and by 2002, the ratio had evened out to 1:1. However the 05 Demographic and Health Survey (DHS) preliminary results reveals an increased feminization of the epidemic in Haiti. Prevalence rates among those aged 20-24 years is 2.4% for females and 1.2% for males. Similar differences between females and males are apparent up through the 30-34 year age range. Age of first sex decreased for both males and females between 1994, 2000, and 2005 with males going from 17.9 (15-24 yrs), to 17.2 (15-24 yrs), to 15.3 (20-24 yrs) and females going from 19.3 (15-24 yrs), to 18.9 (15-24 yrs), to 17.8 (20-24 yrs). The above trends indicate that a strategy promoting and supporting abstinence, delay of sexual debut, fidelity, partner reduction, gender norms, and self-risk assessment are vital to reduce the number of new HIV infections in Haiti.

The USG Team's strategy for averting HIV infections is consistent with the strategies of the Haitian National HIV/AIDS Strategic Plan, emphasizing abstinence, secondary abstinence, delayed sexual debut, and partner reduction, along with outreach and training to empower individuals to make responsible life decisions and practice protective behaviors. In addition, the newly elected government has launched its "Program for Social Appeasement" which targets marginalized, vulnerable groups, especially the youth who are disenfranchised, exploited and prime targets for high risk behavior. The methodologies used are segmented and tailored to be appropriate to the age and risk factors faced by the specific sub-populations. Based on the current epidemiological and behavioral data, FY07 AB programming will focus its efforts to "Being Faithful" messages, especially among men and youth.

Abstinence: Behavior change among the general population is a vital component in the USG Team prevention matrix, and will emphasize abstinence as the only sure way of avoiding HIV-infection. In FY07, the USG Team will continue to build on the strong historical presence of missionaries and faith-based organizations (FBOs), which has been able to quickly engage local nongovernmental organizations (NGOs), community-based organizations (CBOs) and US-based FBOs. This has lead to growing support by adults in changing social norms and increasing parent/child communication around sensitive HIV prevention topics in a culturally appropriate manner. Working with both local CBOs and PEPFAR Track 1.0 partners, the USG Team will continue to successfully introduce abstinence-only messages into these networks, especially for youth. Targeting youth aged 10-19 yrs, partners such as Johns Hopkins University's Center for Communication Programs, Caritas, World Concern, Plan International, World Relief, World Vision, Plan and the American Red Cross, have trained church animators to deliver abstinence only messages to their peers.

The USG Team will build on the USAID work in the education sector in reaching in- and out-of-school youth. USAID's new "Basic Services Strategic Objective" combines health, education and food and nutrition in one program. In FY07, the USG will support several USAID education programs which target youth in- and out-of-school programs in Port au Prince, Jeremie, and Mirebalais and other targeted urban "hot spots" by adding an HIV/AIDS education component to on-going primary school curriculum. The AB program will also build on the successful use of community radio to deliver AB messages as well as discussing gender norms, partner reduction, and risk perception. The USG will also support the integration of HIV prevention messages into USAID democracy and governance program by supporting journalists, community radio and civil society organizations.

Being Faithful: As a result of the more in-depth analysis of the current epidemiological and behavioral trends as well as the USG Team prevention program, more efforts will be given to promoting behavior change among sexually active groups. FY 2007 prevention programming will build on successful risk

reduction and being faithful models to reach several key most at risk populations in Haiti, including sexually active youth, commercial sex workers and their partners, mobile/migrant populations and men in general. Special efforts will also be targeted to increase behavior change interventions in geographic departments with some of highest prevalence rates in Haiti, the Nippes, North and North East Regional Departments.

In order to ensure a continuum supporting behavior change, services will be made available through referrals to USG network sites for most at risk populations, including sexually active youth and men, to condom outlets, voluntary counseling and testing (VCT) services, and diagnosis and treatment for sexually transmitted infections. Both the USG Team and its Track 1.0 AB partners are finalizing activity maps and developing an effective referral network for clinical services. More efforts will be given to encourage all sexually active persons to "Know Their Status."

In FY07, the USG Team will continue to strengthen the leadership, technical capacity, and management ability of the Ministry of Health's (MOH) Prevention Technical Cluster and the Behavior Change Communication (BCC) Cluster. These clusters are multi-sectoral alliances which public sector management of AB/ABY interventions and refocused age appropriate messages of youth HIV prevention programs in NGOs, FBOs, and CBOs. In support of the new government and its desire to decentralize services, more attention will be given to supporting MOH departments and partner NGOs in the regions.

The USG Team's AB program engages adults from diverse community groups, and promotes social norms supportive of healthy/safer sexual behaviors. This includes mobilizing community support to promote abstinence, mutual monogamy and partner reduction, as well as addressing sexual coercion and exploitation of young people, and discouraging older men from engaging in trans-generational and/or transactional sex with young partners. Public dialogue on these topics with community leaders, parents and clergy, coupled with dissemination of practical, culturally appropriate educational materials and counseling guides will encourage adults to reduce their own risky sexual encounters with other adults, as well as with youth. Training adults from FBOs, CBOs and NGOs to promote AB for youth in their communities will not only reinforce safer behaviors among the youth, but will also support the adults own behavior modification.

Policy & Support to Women: During the year, Haiti's continuing gang violence and kidnapping has resulted in increased incidence of rape. Much of the illegal activity is thought to be perpetrated by young men aged 15-24 years. Therefore, linkages with out-of-school youth programs and selected partners will increase HIV/AIDS prevention, rape crisis counseling, testing services and sensitization of police in handling rape cases. Linkages will be made with NGOs and government ministries to address human rights violations and stigma and retaliation against rape victims. Policy and advocacy will be undertaken with support to the media, including female journalist radio networks and the Ministry of Woman and Social Affairs. Linkages will also be made to the MOH initiative to "Reposition Family Planning" to increase protection from both HIV infection and unwanted pregnancies in promoting women's health.

Program Area Target: Number of individuals reached through community outreach that promotes 250,000 HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that promotes 568,650 HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention programs 15,470 through abstinence and/or being faithful

Table 3.3.02:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $440,000

Linked to Activities 9683, 9937, 10109,9676, 9365, 10203, 9292.

SUMMARY: In 2006, Management Sciences of Health (MSH), the institutional contractor for USAID's integrated health services umbrella mechanism, was provided with PEPFAR funds to target youth and other at-risk population groups with abstinence and be faithful (AB) prevention messages. In the fourth year of PEPFAR these targeted efforts will continue to ensure sustainable interventions for promoting prevention activities through local non-governmental organizations (NGOs). Umbrella mechanisms provide the administrative structure and management capacity to build strong local institutions and and generate involvement of local NGOs and CBOs through direct technical assistance and funding by the lead partner. Building on past investments to strengthen the capacity of a network of health NGOs in Haiti, the USG will provide support to include HIV/AIDS prevention into the provision of a basic package of health services for vulnerable groups in Haiti. Funded through USAID, these partners form a network of nearly 100 service delivery sites that provide access to basic health services to nearly 3.2 million people. In FY 2007, special focus will be given to departments with high HIV prevalence, such as the Nippes, North and North East Regional Departments. Many NGOs and CBOs working in these zones have strong ties to the community and are providing other critical development services. Although the USAID contract with MSH will end in September 2007, steps have already been taken to put in place a follow-on program that will be operational by mid 2007, and FY 2007 PEPFAR funding will be put into this mechanism. A new USAID contractor will have been identified by that time through which resources to support CT services in the NGO network will be channeled.

BACKGROUND

With the recent successful elections, the new government has signaled a strong desire to improve basic social services throughout Haiti, including attention to HIV/AIDS prevention. The new government's program recognizes that in order to respond to the basic health that more efforts are required to encourage the involvement of NGOs and the private sector. As a result, the GOH has indicated support for continuing to forge public private partnerships in the rebuilding of Haiti's health sector and the delivery of basic services. Many of USAID's existing partners are in a strategic position, to better integrate Being Faithful messages targeted to couples, men engaging in high risk sex with multiple partners, and especially youth between 15-24 years of age. It is expected that the successful bidder will continue to subcontract with up to 30 local NGOs to better target Abstinence and Be Faithful messages through their network. Many of these NGOs already have organized programs through mother's clubs, father's clubs, youth associations and have expressed interested in incorporating HIV/AIDS prevention methods. Recent DHS data on HIV prevalence and behavioral determinants point to the need to target parts of the country with the highest HIV/AIDS prevalence rates, such as Nippes, North and the North East Regional Departments, the latter on the border with the Dominican Republic, with the most frequently used border crossing. Since many of its current USAID sub-partners are implementing development activities targeted towards vulnerable groups, more efforts will be undertaken in this fourth year of PEPFAR to better integrate HIV/AIDS prevention activities to key groups in these NGO networks. Several opportunities exist to take advantage of existing USG investments and support the new government to better target prevention messages to key client groups at risk for transmitting HIV/AIDS.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: In FY 2007, the USAID contractor will provide small grants for up to 15 civil society NGOs to conduct advocacy activities among community leaders to change community norms in supporting messages to reduce risky sexual behavior. Community leaders, church members, adult volunteers and parents will be trained in planning and implementing abstinence and behavior change programs within their ongoing health and community development programs. Up to 30 adult leaders will be trained (2 from each NGO) who will in turn train up to 20 adults peer educators within their NGO network for a total of 300 adults trained. Adult peer educators will provide information, education and communication services to their peers, including: counseling for discordant couples, linkages to ARV, and care; and promoting messages on mutual fidelity, monogamy, partner reduction and personal risk assessment. Referrals for HIV counseling and testing (CT) will be promoted so adults can know their status and focus on behaviors to reduce

chances of being infected or transmitting HIV to others. During community events, discussions will be held around gender based violence, transactional sex, couple communications and messages which increase community advocacy and support changes in community norms for reducing high risk behavior. Over 6,000 adults will be reached through this activity.

ACTIVITY 2: Similarly, support will be given to youth focused NGOs to accelerate abstinence and being faithful programs for youth, most of them out of school and working in the informal sector . Specifically, up to 20 youth peer/counselors (per 15 NGO/CBOs) will be trained for a total of 300 youth who will target their peers with be faithful and risk reduction messages. It is anticipated that these youth will be identified from existing USAID NGO networks such as youth groups and clubs, local musician networks, sporting associations, local civic associations and community groups. Several sub partners such as the Haitian Health Foundation (HHF), FONDEV, St. Croix Hospital, MEBESH, Fermathe, have strong anchors in the community and located in secondary towns and peri urban areas. Many of these networks are in security "hot spots" and are targets for USAID's new 3-year strategy to support the Government of Haiti in its rebuilding efforts. It is anticipated that civil society groups will promote youth in the planning, design and implementation of training and outreach efforts in order to maximize youth ownership and buy-in. Following training youth peer educators will conduct outreach activities during community events such as carnival, World AIDS Day, sporting tournaments, youth camps, music jamborees and activities frequented by youth. It is anticipated that each peer educator will reach about 50 peers each during the period for a total of 15,000 youth reached with AB messages. Sexually activity youth will be referred to CT, ARV and care and support services and linkages to other USAID reproductive health services, including family planning will be made.

Activity 3: A special focus will be placed on "Being Faithful" interventions which target men where they commonly congregate, such as brothels, sporting events, community and social events. Again, efforts will be undertaken to target USAID network of father's clubs, as well as men through male networks of local celebrities, entertainers, artisans, and transportation networks, Messages targeting these male groups will reinforce themes of fidelity, partner reduction, avoidance of commercial sex and condom use. The needs of HIV discordant couples will be addressed through targeted counseling and education as well as referrals to VCT services and HIV care and treatment services. Counseling and education on prevention of transmission for HIV positive persons, "prevention for positive" will be an integral part of all prevention efforts. Efforts will be made to train male adult leaders and youth, to better target messages to men in supporting behavior change and reducing the spread of HIV.

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $300,000

Linked to Activities 9683, 9791, 10109, 9676, 9365, 10203, 9322.

SUMMARY: In FY06, Management Sciences for Health (MSH)'s Health Systems 2007 (HS2007) Project was provided with PEPFAR funds to accelerate work of its Non-governmental Organization (NGO) health service delivery network in prevention education to target groups at high risk for HIV/AIDS. In FY 2007, the USG will continue to support these targeted prevention efforts and work to ensure sustainable interventions for promoting prevention activities using the USAID Health Office NGO umbrella mechanism that will be the follow-on to the MSH contract. The NGO sub-partners form a network of nearly 100 service delivery sites that provide access to basic health services to nearly 3.2 million people. Special emphasis will be made to target the regional departments of Nippes, the North and North East and work with local NGOs and Community-based Organizations (CBOs) that have strong roots in the community. USG will support these civil society NGOs that can be mobilized to quickly launch condoms and other prevention activities in some of the insecure "hot spots" targeting underserved most at risk population (MARP) groups. The HS2007 project will end in late 2007. USAID is currently designing a new follow on project which will be competitively bid. The new procurement will be an umbrella mechanism which will integrate HIV prevention into local NGOs/CBO networks. The new mechanism will be in place in mid-2007 to allow PEPFAR to accelerate attention to expanding prevention activities that promote responsible sexual behavior, including condom use, for MARP groups.

Prevention activities will target parts of the country with the highest HIV prevalence rates and support NGOs and CBOs in the network to target these high risk groups. The 2005 Demographic and Health Survey (DHS) data suggest that while knowledge in ways to prevent HIV transmission is high—over 90%, condom use is low—30% and accompanied by high risk sexual activity. Partners will work with marginalized communes, peri-urban areas and secondary cities where major pockets of high risk activity take place. Training of network members will include building skills in risk self assessment, condom negotiation, counseling and testing and linkages to care, raising issues related to gender and sexual violence and changing social norms. In 2007, NGO partners will sharpen the targeting of prevention efforts to four key MARP groups: sexually active youth aged 15 to 24; couples; men engaging in high risk sex; and migrant/border populations.

BACKGROUND: Historically there have been only a few strong and widely recognized Haitian NGOs with the managerial and technical capacity to implement effective prevention and behavior change programs targeting specific high-risk populations. In FY 2006, PEPFAR leveled the playing field by expanding the use of the USAID umbrella NGO mechanism, through HS2007, to strengthen the capacity of new smaller, nascent Haitian NGOs, CBOs, Faith-based Organizations (FBOs) and private sector entities to contribute to prevention efforts for targeted populations that typically engage in high-risk behavior. With the recent successful elections, the new government has signaled a strong desire to improve basic social services throughout Haiti, including attention to HIV/AIDS prevention and supporting public private partnerships in the rebuilding of Haiti's health sector. The condom activities and other prevention efforts in this activity are in line with this vision. Sub-partner NGOs working under the USAID umbrella mechanism will target parts of the country with the highest HIV prevalence rates, such as Nippes, the North and the North East Regional Departments, the latter on the border with the Dominican Republic, with the most frequently used border crossing.

ACTIVITIES & EXPECTED RESULTS Activity 1: Support will be provided for advocacy and education by NGO and CBO partners to address key prevention themes, such as promotion of correct and consistent condom use, adoption of personal risk reduction strategies, encouraging HIV voluntary counseling and testing (VCT) among MARPs and prevention education for people living with HIV/AIDS (PLWHA). These themes will be addressed in the following types of activities: 1) training in advocacy techniques for community leaders, 2) training of peer educators and counselors, 3) emphasis on "know your status" messages to create demand for VCT services and 4) ensuring that there are effective referral systems between VCT services and other HIV/AIDS care and treatment services for sexually active youth, couples and men. More aggressive targeting of prevention messages and condom social marketing to MARPs will be done through USAID civil society networks.

Activity 2: Many of these organizations work in socially and politically unstable "hot spots" targeted by USAID's new 3-year strategy. As PEPFAR reaches its fourth year, efforts will be made to create synergies with USAID's education, governance, food security and economic growth initiative to increase prevention messages and positive behavior change among high risk groups. A Rapid Response small grant component will be established for innovative approaches tin reaching high risk group in USAID's network. In particular linkages will be made with USAID job creation program to target 15-24 year olds. Given the continued insecure programming environments, small grants up to $10,000 each will be provided specifically to target HIV/AIDS prevention programming to key groups in existing NGO/CBO networks. Funds will support start up, training and materials to target messages to adolescents and youth through youth groups and clubs; local musician networks, sporting associations, local civic associations and community groups. Special efforts will be made to better target 15-24 year olds to increase awareness of personal risk, reduce the number of sexual partners, address gender and transactional sex and increase correct condom use. Particular focus will be placed on providng women with access to programs that address violence and sexual coercion. Up to 15 civil society organizations or networks will receive small grants to undertake condom and other prevention activities. Up to 150 youth peer educators (10 per NGO) will be trained to reach 50 peers each for a total of 7,500 youth reached with messages on correct and consistent condom use, if appropriate. Referrals will be made to urge counseling and testing and linkages for care and support.

Activity 3: A special focus will be placed on interventions which target men where they commonly congregate, such as brothels, sporting events, community and social events. If possible special efforts will be made to reach unemployed young men, street traders, and members of the informal sector. Efforts will be undertaken to target USAID network of father's clubs, as well as men through male networks of local celebrities, entertainers, artisans, and transportation networks, Messages targeting these male groups will reinforce themes of fidelity, partner reduction, avoidance of commercial sex and condom use. The needs of HIV discordant couples will be addressed through targeted counseling and education as well as referrals to VCT services and HIV care and treatment Counseling on prevention of transmission for HIV positive persons, stigma reductions and "prevention for positive" will be an integral part of all prevention efforts. Linkages will be made as well with the USAID-supported social marketing program to increase condom use among MARP groups such as Commercial Sex Workers (CSWs), MSMs, transporters, mobile populations and sexually active youth. It is anticipated that each NGO partner will train up to 10 male peer educators each to target up to 50 peers each with messages to reduce risky behavior and promote condom use, for a total of 7,500 males reached.

Funding for Care: Adult Care and Support (HBHC): $200,000

Linked to Activities 9683, 9791, 9937, 9676, 9365, 10203, 9314, 9333, 10100.

SUMMARY: The USAID bilateral health program supports a contractor to implement the Health Systems 2007 (HS2007) Project for maternal and child survival, reproductive health and tuberculosis programs, working through a network of non-governmental organizations (NGOs) to offer health care services in Haiti: hospitals, health centers, dispensaries and community networks. The contract with the current implementing institution, Management Sciences for Health (MSH), will end in September 2007; however, a new USAID contractor will be identified and a follow-on program with FY 07 PEPFAR resources to pursue palliative care services in the NGO network through this new contractor will be will be operational by mid 2007.

BACKGROUND: With FY05 and FY06 PEPFAR resources, the United States Government (USG) has taken a series of steps to wrap around the HS 2007 integrated health program, in order to integrate such HIV services as counseling and testing (CT), PMTCT and TB/HIV, basic palliative care and antiretroviral (ARVs) into HS2007 primary health care services. These NGO points of service are dispersed throughout the 10 regional departments of the country and serve about 25% of the population; as such, they represent a good network to expand HIV services throughout Haiti. Most of these points of services are currently offering CT services, and 30% - 40% of them have maternity wards which are delivering PMTCT services.

Four of the most important hospitals in this network are offering ARV treatment services. While a good package of palliative care services has been implemented in these four ARV sites, only limited services are offered in the network's CT and PMTCT sites. With FY 06 PEPFAR funding, the USG will implement a more structured package of palliative care in twenty of these service delivery sites. This package includes mostly clinical care with limited home-based care and community support services. As of March 2006, about 5,000 PLWHAS have received palliative care services in this network. It is estimated that as many as 10,000 PLWHAs will be enrolled by the end of September 2007. In FY 07, USG/Haiti will continue these on-going activities at the various points of service in this NGO network in order to offer a more comprehensive and structured package of palliative care. The primary focus of this effort will be to ensure that all PLWHAS identified at the CT sites get access to a continuum of care at the clinic, community and home levels. At the clinic level, the USG will ensure that PLWHAS benefit from clinical and lab assessment services, as well as follow-up services to treat and prevent opportunistic infections (OI) and to monitor their optimal time for anti-retroviral treatment (ART). At the community level, PLWHAS will have access to social and psychological support services through community-based organizations (CBOs). In addition, PLWHAS will receive a package of home-based care through a network of community workers linked to each clinic. Thus, at each palliative care site, the planned focus will be to reinforce the relationships and linkages with all participants provide this integrated package of palliative care. The USAID contractor will participate in all efforts to coordinate and provide hands-on technical assistance in order to implement this model of care, as well as to develop a standardized package of home-based care and support services with the Ministry of Health (MOH) and other stakeholders throughout the country.

ACTIVITIES AND EXPECTED RESULTS: The USG will provide PEPFAR resources to the TBD contractor to expand palliative care services to 15,000 PLWHAS through the following activities:

Activity 1: Resources will be allocated to reinforce overall service organization for clinical services at 20 existing palliative care sites and at 10 new sites. The focus of this activity will be to make available a package of clinicians, nurses, social workers at the clinic level. Nurses are the backbone for clinical services at these sites. Through the Haitian Group for the Study of Kaposi's sarcoma and Opportunistic Infections (GHESKIO), a new training package, including nursing curricula, clinical tools and human resources capacity development activities, is being developed to train nurses to serve as the main providers of HIV treatment services in health centers and dispensaries. Social workers at these sites will ensure the link with CBOs to enhance access for all PLWHAS to a complete package of social support services

Activity 2: The TBD contractor will expand and reinforce the existing network of

community workers at each site to provide home based care. These community workers, under the supervision of on-site social workers, will conduct home visits in order to track patients and provide counseling services regarding HIV prevention and best health practices, particularly related to safe drinking water, malaria prevention and nutrition. During home visits, these community workers will assess basic care needs of the patients and will provide pain killer as well as other symptomatic medicine, oral rehydration solutions (ORS) and micronutrients according to the national guidelines, as needed. Partners in Health (PIH) will train these community workers using national guidelines, while AIDSRelief will ensure supervision and on the job training for them. Commodities and drugs for this activity will be provided thru Partnership For Supply Chain Management (PFSCM).

Activity 3: Within each department, particular emphasis will be on ensuring that all the palliative care sites in this USAID contractor network are linked with ARV sites, to ensure that eligible patients get access to ART. The network sites will 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 through which the USG will channel resources for social support services.

Activity 4: Resources will be allocated to the USAID contractor to coordinate the program and provide technical assistance through regular visits to the sites in order to ensure that services are both well-organized and adhere to the national model of care. During these visits, all staff will receive on-the-job training. These resources will allow the contractor to hire and support appropriate staff to oversee this program and to provide quality assurance/quality improvement (QA/QI) to all palliative care sites in the network.

Gender Equity: The program will target women as well as men. A particular emphasis will be placed on women from the PMTCT program.

Funding for Care: TB/HIV (HVTB): $100,000

Linked to Activities 9264, 9286, 9675.

SUMMARY: The primary emphasis for these activities is the training of the tuberculosis (TB) clinical services providers in HIV/AIDS, the training of the counseling and testing (CT) clinical personnel in TB, in quality assurance and control (QA/QC) at TB and CT sites. Specific target populations include physicians, nurses, laboratory technologists, auxiliary nurses and field agents. The activities will be carried out in eleven facilities located in the North East, North and West Regional Departments.

This project is part of a larger initiative begun in 1989 through a partnership between the Centers for Development and Health (CDS) and the Ministry of Health (MOH) according to which CDS directly managed infrastructures and personnel provided by MOH. In 1994 CDS signed a subcontract with MOH in order to supervise TB activities in the whole North East Department. The CDS TB activities were funded through the USAID NGO umbrella contract with Management Sciences for Health (MSH) and by the Global Fund. TB/HIV integration started in six facilities in the Northeast Department in 2006 under the CDS project funded by PEPFAR. Although the USAID contract with MSH will end in September 2007, steps have already been taken to put in place a follow-on program that will be operational by mid 2007, and FY 2007 PEPFAR funding will be put into this mechanism to continue support to CDS. A new USAID contractor will have been identified by that time through which resources to support CDS TB/HIV activities will be channeled.

These activities are part of the MOH strategic plan. Consequently the North East, the North and the West Regional Departmental directorates will play a key role in the supervision process.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: The first activity is to provide comprehensive counseling and testing through the existing TB clinics and to integrate the CT and tuberculosis services where those programs already exist. Integration is already effective at six facilities where patients seen for TB are also counseled to be screened for HIV/AIDS. It is also the case for HIV patients. HIV patients are screened for TB using PPD (Protein Purified Derivative). Patients with symptoms such as cough, fever, sweating, etc, are screened for TB through sputum smear and treated for TB, as appropriate and necessary. Six months of preventive isoniazid (INH) will be administered to HIV patients with positive PPD tests. TBD will train both HIV and TB services providers, building renovation in order to provide adequate pretest and post-test counseling, to equipping XX facilities, and training central and regional supervisory staff to ensure a minimum quality standard for the services.

ACTIVIY 2: CDS will reinforce the referral network between Diagnostic and Treatment Center (CDT) and Treatment Post (PT). TB will be treated at the PT level while diagnosis by sputum analysis is taken place at the CDT. TB patients will be seen once a week or every two weeks by the CDT counselor depending on the number of patients diagnosed for TB.

ACTIVITY 3: CDS will train staff of 11 sites to diagnose HIV among TB patients using HIV rapid test kits. TBD will build the capacity of 11 sites by training staff to meet the increasing need for counseling services among TB patients.

Funding for Care: Orphans and Vulnerable Children (HKID): $625,000

Need narrative.

Table 3.3.08:

Funding for Prevention: HIV Testing and Counseling (HVCT): $250,000

Linked to Activities 9683, 9791, 9937, 10109, 9676, 10203, 9362.

SUMMARY: Management Sciences for Health (MSH), the USAID contractor that implements USAID's Health Systems 2007 (HS2007) Project for maternal and child survival, reproductive health and tuberculosis programs, works through a network of NGOs which offer services at different levels of the Haitian health care system: hospitals, health centers, dispensaries and community networks. With FY 2005 and FY 2006 PEPFAR resources, the USG has taken a series of steps to wrap around this program, in order to deliver integrated HIV services. These NGO points of service are dispersed throughout the 10 regional departments of the country and serve about 25% of the population; as such, they represent a good network to expand HIV services throughout Haiti such as: CT, PMTCT, Palliative Care and ARV treatment. The backbone of these programs remains the counseling and testing (CT) services that in FY06 are offered in 30 sites covering 80% of the points of services of this network.

As of March 2006, 25,000 people have been tested through this network. In FY 2005, these CT services were delivered in a vertical manner with limited integration with other HIV/AIDS activities, weak demand creation efforts and limited counseling to partners and family. With FY 2006 resources, steps are being taken to fill in these gaps to expand quality CT services to 75,000 people by September 2007. The USG will use FY 2007 resources to continue strengthening CT services thru this network in order to reach the overall USG objectives to test 300,000 people per year.

BACKGROUND: Although the USAID contract with MSH will end in September 2007, steps have already been taken to put in place a follow-on program that will be operational by mid 2007, and FY 2007 PEPFAR funding will be put into this mechanism. A new USAID contractor will have been identified by that time through which resources to support CT services in the NGO network will be channeled.

Emphasis will be placed on reinforcement of service delivery sites to ensure that CT is being integrated into all wards of the facilities, particularly the maternity ward, the TB clinic and the general care ward. Last year a model of mobile CT services was successfully launched in one of the PEPFAR-supported NGO networks. The USG will take steps to expand this model of mobile CT to NGOs in the USAID-supported NGO network with a strong community arm. More demand creation activities will be carried out at and around these CT sites to ensure effective use of these services. A particular emphasis will be put on improving the quality of counseling by improving post test counseling in adherence and protective behavior to provide necessary support to PLWHA to keep them in the care system, access their partners and family and encourage protective behavior. At the regional departmental level, these CT sites will be linked to the palliative care sites as well as to the PLWA support groups to ensure a continuum of services to PLWHA.. The USAID contractor will participate in all efforts to coordinate and provide hands-on technical assistance in order to improve the quality of counseling and testing services, as well as to develop a standardized model of mobile C&T services with the MOH and other stakeholders throughout the country.

ACTIVITIES AND EXPECTED RESULTS: The USG will provide PEPFAR resources to the TBD contractor to provide counseling and testing services to 100,000 people through the following activities:

Activity 1: Support will be provided to 30 existing and 10 new points of services within the network to reinforce their service organization to integrate CT services 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. CT clients will be counseled and referred appropriately to family planning and sexually transmitted infection services. Funding will cover space refurbishing 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: Site and community-based HIV testing promotion will be reinforced to create demand and encourage people with risky behavior to be tested. Resources will be allocated to procure equipment and materials for promotional activities (TV, VCR) for the sites; produce posters, brochures and other materials to be distributed to targeted populations along with banners and street signs to create greater awareness of the opportunity offered by the facilities. Posters encouraging testing will be placed on prominent locations throughout the facilities. This will be done in integration with the HIV community mobilization program that will be reinforced around the different sites.

Activity 3. The TBD PHN Contractor will work through the ITECH/INHSAC CT training program to ensure that each service provider at the 40 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 C&T, particularly the psychological, adherence and protection 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, family planning and reproductive health services and sources of support for income generation activity.

Activity 4: The TBD contractor 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 C&T QA/QC team that will periodically visit all sites, use a supervision checklist, and ensure that all sites respect norms regarding C&T. In addition, at this time, no clear effective policy is applied by C&T site personnel in case of discordant results in couples. The TBD contractor will participate in all efforts to help the MOH integrate its facilities into a program that will examine the best policies for counseling couples on discordant results.

Funding for Treatment: Adult Treatment (HTXS): $1,975,000

Linked to Activities 9683, 9791, 9937, 9676, 9365, 10203, 9332, 9313.

SUMMARY: USAID Haiti implements an integrated maternal and child survival program through a network of nongovernmental organizations (NGOs) called the Health Systems 2007 Program under contract with Management Sciences for Health (MSH). With the President's Emergency Plan for AIDS Relief (PEPFAR) resources the United USG took steps to wrap around this NGO integrated health program in add HIV activities that includ counseling and testing (CT), PMTCT, palliative care and anti- retroviral (ARV) services. The ARV services are implemented in four network NGOs (Management and Resources for Community Health [MARCH] Hospital in the Central Plateau, Beraca Hospital in the North West, Grace Children in the West department and the Communauté de Bienfaisance de Pignon [CBP] Hospital in the North East). With FY06 resources, these services are being expanded to one additional network institution: the public sector Fort-Liberté Hospital in the North East Regional Department. As of September 2006, close to 600 patients have been enrolled on ARVs through this network. With FY06 resources, the USG expects that at least 400 new people living with HIV/AIDS (PLWHA) will be enrolled on ARVs in this network. In FY07, ARV services will be available in one additional network site: Ouanaminte Hospital in the North East Regional Department.

Although the current USAID contract with MSH for the maternal and child survival program will end in 2007, steps are being taken to put in place a follow on program. A new USAID contractor will be selected by mid-2007 so that activities, including the expansion into one new site, can continue without interruption.

BACKGROUND: These five sites are strategically located for the expansion of the program. The USG has wrapped around existing child survival resources at all five sites, particularly their network of community services, to implement the model of ARV care based on good assessment of patients (clinical and lab), regular follow up of patients, good pharmacy plan and community support for adherence to treatment. Further, the entry door for ARV services has been the VCT, the PMTCT, the palliative and the TB care programs that are being reinforced at these sites. Resources were given to strengthen human resources, enhance infrastructure and support minimal social costs for patients. In addition, resources were allocated to Haitian Group for the Study of Kaposi's sarcoma and Opportunistic Infections (GHESKIO) to support training and quality assurance and quality control (QA/QC) at these sites which have been capacitated with electronic medical record (EMR) and automated drug management systems.

In general, although the implementation of HIV/AIDS services at existing sites has been successful, some of them are not taking full advantage of all opportunities to enroll patients on ARV treatment, therefore, performing below expected outcomes and targets. The resources allocated to these sites were not sufficient to provide all necessary inputs such as human resources and infrastructure. In FY 07, more resources will be needed to maintain and to expand this program at these five sites.

ACTIVITY AND EXPECTED RESULTS: Activity 1: TBD will reinforce overall service organization to make available a better package of human resources (clinical and community) and better infrastructure to expand both ARV treatment services at clinic and home levels. Emphasis will be placed to allocate more physicians, psychologists and social and community workers and to do necessary infrastructure renovations. Emphasis also will be put to initiate and/or improve pediatric treatment services. Home-based care will be reinforced to ensure better tracking of patients and to provide some basic follow up of treatment at home as well as support to PLWHAs and their families.

Activity 2: TBD will support logistics and provide materials and supplies needed for home-based care and tracking of patients.

Activity 3: TBD will coordinate the program and provide technical assistance to the sites to ensure that the services are well organized to respond to the model of care through regular visits. TBD will provide onsite training of staff at the sites. TBD will hire and support appropriate staff to oversee this program and to coordinate with GHESKIO QA/QI and training activities for these sites.

Funding for Health Systems Strengthening (OHSS): $100,000

In an effort to reduce management units, USAID has decided to eliminate The Futures Group's Health Policy Initiative as a local parter and instead reprogram these Policy Analysis and System Strengthening funds to the Management Sciences for Health who will implement the activities. Linked to Activities 10308 and 9312. SUMMARY: The Health Policy Initiative (HPI) seeks to improve the policy environment for the HIV and AIDS efforts by improving the implementation of national strategies and policies and by building the capacity of national, regional, and community-based organizations (CBOs) to lead a sustainable response to the HIV epidemic in Haiti.

BACKGROUND: The Health Policy Initiative Task Order 1 (HPI TO1) is a new program with the mandate to support the President's Emergency Plan For AIDS Relief (PEPFAR) goal of building sustainable local expertise to provide prevention, care, support and treatment in Haiti. HPI TO1 will provide practical and technical support for the implementation of HIV/AIDS programs through building capacity to address operational barriers which impede the implementation of laws, policies and programs. The HPI TO1 technical assistance will also strengthen the policy environment for HIV by supporting national and departmental leaders in developing and introducing new laws which protect the rights of people living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVC). HPI will work with faith-based groups (FBO) and with the private sector to reduce stigma and discrimination. In FY07, HPI will build the capacity of the Ministry of Health (MOH) to develop or clarify policies related to opt-out HIV testing and double orphans. These efforts will be realized in close collaboration with the MOH and other Government of Haiti (GOH) entities. HPI will collaborate with "Promoteurs de l'objectif ZEROSIDA" (POZ) and World Relief (WR) to implement several of these activities.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: HPI will collaborate with POZ and World Relief to improve the knowledge and attitudes of religious leaders and assist them to develop interventions to address S & D through church activities, sermons, and community outreach. HPI will work with POZ and WR to develop and adapt training materials and methodologies; POZ and World Relief will then train pastors in approximately 100 churches. Where feasible, we will bring pastors in the same regions together to discuss their successes and challenges and learn from each other. Anticipated results: Enhanced HIV/AIDS knowledge and decreased S & D among the FBO communities.

Activity 2: HPI will provide technical assistance (TA) to the MOH to reinforce the normative, planning and coordinating roles of the fight against HIV/AIDS. For example, HPI will support MOH in the development of a national anti-retroviral therapy (ART) SCALE-UP Plan, participate in the assessment of human resources (HR) needs for HIV/AIDS service delivery, and participate in the formulation of policies on crisis counseling and testing (CT) for victims of violence.

Activity 3: The GOH has recognized the need for an overarching law to protect the rights of HIV-positive people and those most at-risk for HIV in legal areas such as: opt-out or provider-initiated HIV testing; protection against S & D in the workplace, including job-protection policies for HIV+ personnel; inheritance rights of OVC; identifying who holds legal responsibility for dual (paternal/maternal) orphans; determining the necessary legal criteria for obtaining permission to test and care for OVC; law enforcement to protect OVC from trans-generational sex, resulting in increased risk for HIV/AIDS; addressing gender inequities in access to schooling and vocational training; and ensuring that HIV+ women have equal access to microfinance and income-generation programs. HPI, in collaboration with the MOH and other government and civil society stakeholders, will facilitate a series of consensus meetings to review conventions and laws adopted in other countries and, based on this review, provide technical assistance to legal advisors and parliamentarians to draft a National AIDS Law. HPI will support the involvement of PLWHAs, women and at-risk communities to participate in these stakeholder meetings (see Activity 2).

Activity 4: In coordination with capacity building for the Haitian Parliament and other stakeholders to develop a National AIDS Law, HPI will support capacity building for public and civil society organizations (e.g., ministries, police departments, women's groups,

youth groups, business associations) to support passage of the National AIDS Law. HPI staff will conduct trainings with 10 organizations in advocacy and policy dialogue so that these groups can more effectively participate in national discussions about the law. Training will focus on increasing participants' knowledge about HIV/AIDS and the legal and regulatory process in Haiti as well as building skills in developing advocacy messages for local and national policy makers to support the Law.

Activity 5: HPI, in collaboration with POZ, will train a core group of trainers who will conduct advocacy training with PLWHA networks in Port-au-Prince. The training of trainers (TOT) will be supported through small grants. HPI will ensure that women and other at-risk groups are included in these trainings. Participants will develop action plans to perform advocacy in their communities following the training. HPI will provide on-going technical assistance to these networks to address barriers identified by the trainees. Lessons learned from this activity will be incorporated into future training and barrier analysis for PLWHA networks in other departments of Haiti in FY08. Anticipated results: Strengthening the leadership of PLWHA networks and a greater involvement in policy decision making.

Activity 6: This activity will continue work started through the HPI Core-funded (FY 06) operational policy barriers analysis. The Core-funded activity will analyze key operational policy barriers that impede the scale-up of programs in a Program Area designated by the USG team and its partners (e.g., HIV testing and behavior change among uniformed personnel). The Core-funded activity will also identify corrective actions needed to address policy and program barriers. HPI Haiti staff and consultants will use field-support funds to address additional key operational policy barriers and work with multi-sectoral stakeholders to implement the corrective actions and reduce or remove operational policy barriers related to the program area.

TARGETS: •3300 individuals (3000 church members, and 300 individuals of religious staff and religious leaders) trained in HIV related stigma and discrimination reduction •340 individuals (40 members of PLHIV networks, 300 religious staff and religious leaders) trained in HIV-related institutional capacity building •10 public and civil society organizations (e.g., ministries, police department, women's group, youth groups, and Private sector associations) provided with technical assistance for HIV-related policy development. •A National Coordination Plan is developed and approved by the AIDS Coordinating Control Unit (UCC) •A national AIDS law is formulated and trained parliamentarians, public/private sectors stakeholders conduct advocacy for the passage of the law.

Table 3.3.14: