Linked to Activities 9313, 9282, 9343, 9923.

SUMMARY: With resources for this activity, CDC will provide assistance to the MOH and its implementing partners for HIV treatment services to establish Quality Assurance and Quality Improvement (QA/QI) programs by implementing the HIVQUAL program in Haiti. This support will help to ensure that treatment practices meet the country's national standard through systematic assessment and improvement of the quality of the services provided. CDC will focus on building human capacity, making necessary tools available and providing technical support to establish a pilot project in at least 10 sites. This activity will also upgrade physical assets at those health care facilities providing comprehensive long-term care and support to HIV/AIDS patients to enable the facilities to improve quality of care. The activity includes the procurement, warehousing and distribution of basic office and medical equipment for the care and support sites, including the ARV sites that will also provide palliative care to their patients.

BACKGROUND: Over the last three years, the United States Government (USG) Team has built on the success of the two treatment models implemented by Partners in Health (PIH) and GHESKIO to reinforce and expand ARV services in Haiti. As of now, thirty-two sites provide anti-retroviral treatment (ART) in the country through the PIH and GHESKIO networks and two additional networks, Catholic Relief Service Consortium (CRSC) and Management Sciences for Health / Health Systems 2007(MSH/HS2007). The continued expansion of anti-retroviral therapy (ART) delivery in Haiti has shown great progress in improving quality of life and reducing HIV-related morbidity and mortality.

The USG in Haiti has encouraged each major partner to incorporate quality improvement (QI) into program activities of the different networks. In addition, GHESKIO was assigned the responsibility to provide QA/QI at the national level. However, there is lack of standardized tools and guidelines to implement such as a program. Also there has been a lack of systematic plans to improve the quality of services throughout the program.

The USG will use the HIVQUAL system and materials, which have been widely used in the US and adapted for ambulatory care in settings like Haiti, to improve QA in the country. The USG will adapt the HIVQUAL for Haiti to support clinical data collection and analysis at the clinic level, linking these activities to the development of systems that facilitate the improvement of processes and outcomes of care and to provide the capacity for self-assessment.

The lack of adequate physical assets at care and treatment facilities in Haiti has also been a barrier to improving quality of care. The limited funding and lengthy administrative process for accessing the funds for improving infrastructure and equipment prevent the Ministry of Health (MOH) from making necessary upgrades to the physical assets of the publicly-managed health care facilities in the country. The situation is not better for most of the Non-governmental Organization (NGO) centers, which receive on-going support to sustain their primary health care operations or to procure supplies to face emergency situations, but rarely receive resources to procure needed equipment. Therefore, both publicly-managed and NGO facilities are facing a severe shortage of office and medical equipment, which hampers their effort to improve the quality of care. As the number of sites providing care, including ARV therapy, is expected to grow from 20 in FY05 to 65 in FY 07 and as the number of patients is expected to increase from 1,500 at the time the of the first equipment purchase to over 15,000 in 2007, there is a need to procure and distribute additional equipment to the sites.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: With FY07 resources, HIV/QUAL will be implemented in 12 pilot sites for the initial phase. CDC, in collaboration with MOH and other stakeholders, will choose the pilot sites, which will be a mix of public, private, center of excellence and peripheral sites. CDC will form a team of MOH and key partner representatives to conduct an assessment of current QA and QI activities and provide consultation on the development of HIV-specific QI systems, in concert with existing clinic quality management processes and with national QA initiatives. During this assessment, the team will designate a quality assessment staff at each site, select clinical indicators for performance measurement, modify the software for appropriate indicators, provide training and collect data. Following data collection, the team will initiate QI projects should to incorporate the results obtained from the first round of data collection. The

HIVQUAL pilots will start with adult care indicators and will be adapted to pediatric care.

Activity 2: At MOH, a project coordinator, data manager and Information Technology specialist will be designated to support the QI staff at each facility. The country project coordinator will collaborate closely with the USG Strategic Information (SI) Specialists to facilitate indicator and tools development and assessment processes. Project management will include coordination of activities with other services and projects; coaching in QI and organizational development; assessment & monitoring of progress at each site; monthly conference calls with consultants; and coordination with key stakeholders.

Activity 3: CDC/Atlanta will provide technical assistance to oversee the development of the pilot project in the country. Resources will be used to cover logistical costs and per diem to travel to Haiti, to assist in the initial assessment and to monitor the implementation and scale up of the HIVQUAL Project.

Activity 4: Procurement of office and medical equipment. Based on past experience, the list of equipment to be provided will include: stethoscopes, sphygmomanometers, observation tables, delivery tables, bed sheets, exam lamps, medical bed separators, beam and portable scales, desks, office and metallic folding chairs, file cabinets, electric fans, and water dispensers. Procurements will be done centrally using either USG structures or the Ministry of Health Executing Unit as a centrally established procurement mechanism allowing for economies of scale in procurement and transportation.

Activity 5: Warehousing and distribution of equipment. CDC operates a warehouse that handles the office and medical equipment for the USG. CDC has established an inventory system supported electronically by an application named "HARDCAT" that tracks equipment and goods provided through that mechanism. The amount requested for this year will serve to increase the logistics capacity for distribution to the sites, including the acquisition of a heavy duty truck with a large bed, 2 pick up trucks and operating costs for the warehouse. The USG team is investigating the possibility of co-locating the warehouse space for this activity with the warehouse space that will be used by the Partnership for Supply Chain Management to stock PEPFAR purchased HIV/AIDS commodities.

Linked to Activities 10242, 9311, 9337, 9283.

SUMMARY: This activity will strengthen the national laboratory capacity of the Ministry of Health (MOH) by helping to establish: pediatric diagnosis testing by standard dried blood spot polymerase chain reaction (DBS PCR), and an alternative ultra-sensitive protein 24 antigen (P24Ag) assay; viral load testing; a quality assurance/quality control program (QA/QC) for such testing; and, a Laboratory Information System (LIS). The Laboratory Technical Working Group at the Office of the Global AIDS Coordinator (OGAC) led by CDC Global AIDS Program (GAP) International Laboratory Branch and other USG senior staff is recommending the use of DBS Amplicor Deoxyribonucleic acid (DNA) PCR testing for early infant diagnosis (EID). This recommendation was endorsed by the World Health Organization (WHO)/United Nations Children's Fund (UNICEF)/CDC infant diagnosis meeting in May 2006.

ACTIVITY AND EXPECTED RESULTS: Activity 1: The CDC/ GAP International Laboratory Branch will provide technical assistance to Haitian Group for the Study of Kaposi's sarcoma and Opportunistic Infections (GHESKIO) and NPHL laboratory personnel in setting up a EID by DBS PCR test, as well as the ultra-sensitive p24Ag tests. GHESKIO and the NPHL Staff will be trained to set up equipment, understand the principles of each test, hands-on conducting of the test, precautions, method validation, data analysis and reporting results, designing forms for reporting, sample coding, and, lastly, troubleshooting.

Activity 2: The CDC/GAP International Laboratory Branch will assist GHESKIO and the NPHL to set up and participate in the CDC QA/QC proficiency testing program for EID by DBS PCR. The funding for this activity will cover for overseas shipment of QA/QC panels three times annually.

Activity 3: The CDC/GAP International Laboratory Branch will assist the NPHL and three selected ARV labs to work together with the International Training and Education for HIV (I-TECH) to provide technical assistance for the selection of appropriate LIS to be set up at those labs, and supportive supervision.

Activity 4: CDC will procure two vehicles to provide efficient transportation for laboratory consultants who currently rely on over-subscribed official CDC motorpool transportation to conduct field visits, site assessment, and to provide supportive supervision. Haiti does not have safe public transportation. Most lab consultants are dependent on safe transportation provided by CDC Haiti. Current CDC vehicles are not sufficient to provide logistics support to the increased numbers of consultants. In FY 07, at least 18 laboratory advisors will provide technical assistance. Each advisor will conduct multiple visits. CDC will also procure one pick up truck for transportation of big items needed for improvement of laboratory infrastructure, including inverters, batteries, lab benches, lab chairs, solar panels, and refrigerators.

Activity 5: The CDC /GAP International Laboratory Branch will support NPHL and USG Team laboratory staff to attend training courses and scientific conferences as appropriate.

TARGETS: 2 GHESKIO and 2 NPHL lab staff trained in early infant diagnosis 2 pediatric diagnosis labs at GHESKIO and the NPHL established and operated GHESKIO and the NPHL participated in the DBS PCR QA/QC program 1 national and 3 ARV labs guided in Laboratory Information System 4 members of NPHL trained in HIV laboratory methods and participated HIV-related laboratory scientific conferences

Linked to Activities 9923, 10242, 9284, 9310, 9341.

SUMMARY: CDC will provide a selected range of support to the United States Government (USG) implementing partners in order to sustain their capacities to develop HIV/AIDS strategic information systems. This supply-driven support will enable the USG to leverage the impact of its overall contribution to the national HIV/AIDS program. The support will encompass: (i) hands-on technical assistance to collaborating partners by USG regional health information officers (RIO) in the 10 regional departments to coordinate partner interventions and provide support in skill-intensive domains in short supply in Haiti; (ii) cross technical assistance among sites within the concept of "Centers of Excellence". Under this concept, the ARV sites established at departmental hospitals will provide technical assistance and mentoring in various areas, such as voluntary counseling and testing (VCT), palliative care, and health management information system (HMIS) to less-complex, peripheral sites; (iii) sponsorship of local indigenous staff at international forums, workshops and seminars with the objective of developing in-country expertise in SI. The emphasis areas are information technology (IT), USG database and reporting systems. The primary beneficiaries are the Ministry of Health (MOH) staff, community-based organizations (CBO), non-governmental organizations (NGO) and other implementing organizations.

BACKGROUND: The USG direct support for SI efforts has been carried out since 2005 to ensure greater coordination of activities; maintain in the field highly-skilled professionals that would not otherwise be available; consolidate investment in IT; and guarantee availability of data for SI purposes. Five RIOs have been hired and detailed to the regional departments of the country with each RIO covering more than one department. They are seconded by the MOH regional departments and travel throughout their assigned regions to provide support to the MOH, the sites, and local partners in areas such as: HMIS; commodity and drug management; and overall project management to ensure that mechanisms are in place for the collection, processing, and analysis of data for decision making. RIOs currently support 103 VCT, PMTCT, palliative care and ARV sites scattered throughout the country.

In FY06 funding was provided to support participation of local personnel at international forums, workshops and seminars with the objective of fostering a new breed of local SI professionals who will be able to sustain the SI system being implemented. SI professionals must acquire the skills that are crucial to the successful implementation, design, monitoring, and evaluation of HIV/AIDS programs. As a result, several candidates have participated in or will attend the following courses: an M&E course, offered by Monitoring and Evaluation to Assess and Use Results (MEASURE), which covers the fundamental concepts and tools for monitoring and evaluating HIV/AIDS programs; a management-by-objectives and performance-indicator training course; a web-based security course offered to partners running web-based programs; a basic statistics course; and the sustainable management program (MPIH). To promote gender equity and create more opportunities for women in the SI field, the primary beneficiaries of these courses will be the site managers usually recruited among the more seasoned nurses and data clerks, the majority of whom are women. Efforts will also continue to identify and select participants from people living with HIV/AIDS (PLWHA) associations

ACTIVITES AND EXPECTED RESULTS: Activity 1: CDC will provide hands-on assistance through RIOs and cross-assistance among participating sites. The five RIOs will travel throughout their assigned departments to support departmental directorates, service sites and community-based local partners. To encourage best practices and foster sharing of experiences, RIOs will encourage cross assistance among the sites, a practice by which the most experienced field personnel at referral sites travel to assist other personnel at peripheral sites.

Specifically, CDC, through the RIOs, will provide leadership in the development, rolling out and maintenance of data management systems aimed at supporting the national HIV/AIDS program; establish local-area and regional networks for the sharing of information between participating entities located in the coverage area; provide assistance and on-the-job training to health care providers, field data personnel, and regional authorities to improve data collection, reporting and processing; support the data quality assurance (QA) process and participate in field data validation visits; lead efforts to

streamline data flow and data collection in all sub-systems in the program; participate in the establishment and the maintenance of a management-by-objective system with regular monitoring of established targets; and maintain good relationships and coordinate efforts with local authorities, facility personnel, and all USG partners in their assigned areas.

In addition, CDC will procure two additional vehicles to be stationed in the departments. CDC will also provide insurance, required maintenance, and fuel for the vehicles, and will also cover travel expenses for the RIOs and the field staff in the performance of their duties.

Activity 2: CDC will support the development of in-country SI expertise through sponsorship of field personnel to international workshops. Such sponsorship in FY05 and FY06 led to greater involvement and leadership from sponsored professionals. Opportunities will be sought to train people in management of community-based information systems. Among other areas of interest are: M&E; HIV/AIDS surveillance; tuberculosis (TB)/HIV surveillance; IT; methodologies and techniques for conducting Behavioral Surveillance Surveys (BSS) and antenatal surveys; and projections and estimation techniques.

Specifically, CDC will regularly update the list of prospective training opportunities; identify potential candidates in collaboration with the MOH and partners; work with selected participants to ensure application of workshops or seminar contents upon return; facilitate registration and room and boarding arrangements for participants; and maintain a database of participants.

Linked to Activities 9347, 9344.

The roles and responsibilities of CDC's management and technical staff personnel range from management of the overall President's Emergency Plan for AIDS Relief (PEPFAR) program to providing onsite technical assistance and training, including financial management technical assistance to the both the Ministry of Health (MOH) and the United States Government (USG)'s institutional partners. In addition to the usual management and staffing issues of all USG agencies under the umbrella of the U.S. Embassy, CDC's Haiti Global AIDS Program (CDC Haiti) office is responsible for implementing a single public health program, CDC's portion of the PEPFAR program. CDC Haiti does not operate within a larger in-country agency context for its administrative support service, thus it has responsibility for its own contingency planning and US security requirements, such as the planned purchase of a second Lightly Armored Vehicle; leasing and minor renovation of a secure warehouse for lab supplies/equipment; and addressing turnover of locally-employed support and the need to recruit and train replacement staff.

In order to better implement the PEPFAR program with a goal of long-term program integration and sustainability, CDC Haiti will undertake the following management activities in FY 2007: continue ongoing USG team-building to assess specific training and development needs; continue to recruit staff for vacant field positions, especially vacant care and treatment specialists and health information specialists located at the regional departmental level; develop a dedicated high-risk prevention section to work jointly with USAID counterparts in the area of prevention strategies for high risk populations, with a Personal Services Contract(PSC)/Public Health Advisor as Section Chief; lease a new, secure warehouse facility; establish warehouse operations to ensure that commodities and supplies are received safely and distributed in a timely fashion throughout the country, and also that supplies are refrigerated as appropriate and distributed in the same manner throughout the country. The current CDC warehouse was new last year, having been established when we were asked to leave the US Embassy warehouse in 2005; however, the new Airport Road, while in a better part of the insecure ‘red' zone, is still subject to periodic security concerns, so we will be forced to secure a new facility much nearer the new Embassy construction area at Tabarre.

CDC Haiti is currently recruiting for a new Chief of Party/Country Director, as well as a US PSC to head up its high-risk prevention activities, and plans to have both positions filled early in FY 2007. Both of these positions were vacated in FY 2006. Additionally, CDC Haiti will fill a vacant Medical Director position from within its locally-engaged technical staff. In order to increase significantly administrative and technical oversight of its cooperative agreements, CDC Haiti will recruit two additional financial managers who, working under the Chief Administrative Officer, will provide increased administrative and financial oversight of cooperative agreements, including an enhanced audit function, while working closely with the technical leads in each area to provide detailed monthly and quarterly updates of partners' progress. CDC Haiti will also hire a new administrative assistant and back-fill a procurement assistant who is co-located in the Embassy procurement section, to facilitate CDC procurements.

CDC and USAID, in a coordinated effort to ensure adequate technical coverage and avoid duplication of human resources, have a complementary roster of technical advisors that is based on core institutional competencies and experience. As of September 2006, thirty-five (35) CDC staff members are directly supported by the PEPFAR budget, including two vacancies and four 'in-process' positions. Of these 35 staff, three (3) are US Direct Hires (USDH), including the Chief of Party, the Deputy Director, and the Laboratory Section Chief, who is a Senior Service Fellow (a personnel appointment equivalent to USDH positions, but allocated to non-US citizens). The remaining staff is Locally Engaged Staff (LES) or partner-funded laboratory and support staff. The Port au Prince CDC office houses both professional (technical, financial staff, Information Technology (IT) staff, procurement and inventory management) and support (secretaries and drivers) staff.

Approximately 30% of the staff, consisting of both professional (e.g., regional care and treatment specialists and regional information specialists) and support (driver/clerks) are located in small, regional offices throughout the country (e.g., Cap Haïtien and Saint Marc, in the north; Les Cayes; Jacmel; Jeremie, in the south) in association with the MOH's Regional Departmental hospital system, at these various regional locations. The

decentralization of CDC staff at the regional department level is a reflection of CDC's lead role in PEPFAR care and treatment implementation, and the need to institutionalize PEPFAR activities at the local MOH level to the maximum extent possible. Moreover, given the ongoing security concerns in Haiti, the USG Team recognizes the crucial need for program implementation to continue unhindered at the regional department level, regardless of security situations which may occur in the capital. Decentralization is designed to permit program implementation to continue, even if critical events result in further security interruptions, and other management challenges.

To supplement CDC Haiti resident staff, funds are reserved for targeted technical assistance from CDC Atlanta on a broad range of technical issues, policy development, and documentation activities to bring more analytical and evidence-based design to the PEPFAR Program. Funds are reserved for staff training, travel for field program supervision and technical coordination in and outside of Haiti. Commodity procurement includes purchase of additional office equipment. Infrastructure expenses include security and related office upgrades and administrative expenses. Logistics include staff overtime and vehicle maintenance, insurance and fuel.

Added February 2008: The New York AIDS Institute will be providing technical assistance to the PEPFAR-supported ART sites, as well as other ART services in the National Program under the MOH to ensure quality of services and quality improvement (QA/QI). $100,000 is being reprogrammed from CDC M&S funds to the NY AIDS Institute for this purpose.