TB diagnosis that need to be filled in. The NPHL wishes to use the funding from FY 07 to rapidly strengthen the quality assurance program for AFB smear microscopy in Haiti.

ACTIVITES AND EXPECTED RESULTS:

Activity 1: NPHL will establish internal quality control to be used in the 184 centers for diagnosis and treatment that constitute the TB laboratory network. These will include but not limited to USG-supported ARV laboratories at departmental hospitals, palliative care laboratories and TB laboratories. QC helps to ensure that the results produced by a laboratory are accurate, reliable, and reproducible and that the data that are sent to the central level for analysis by the Coordination Unit of TB and HIV programs are reliable. These QC activities include laboratory arrangement and administration, bio-safety, laboratory reporting forms, staining reagents, and smear examination,. NPHL lab staff will organize a QA/QC workshop for TB lab staff to reinforce their knowledge on internal QC and prepare for the national External Quality Assessment program for TB microscopy. .

Activity 2: The NPHL will establish the national EQA program for TB direct smear diagnosis to help laboratories identify errors and improve good laboratory practice in order to achieve for better performance. Three methods will be used to evaluate laboratory performance. They include onsite evaluation, panel testing and blinded slide rechecking.

Onsite evaluation: NPHL staff will visit and evaluate 100 laboratories (ARV, palliative care, and TB labs) that perform AFB direct smear microscopy both public and private sectors once a year. During such visit, the internal QA of TB laboratories will be evaluated, and corrected recommendations and trouble-shootings will be provided by expert TB NPHL lab staff. NPHL will be proactive in this activity to provide onsite evaluation to larger number of TB laboratories and focusing on the internal QA.

Panel Testing:. NPHL will send out a panel of stained and/or unstained slides to 100 peripheral sites countrywide at least once a year for reading and interpretation. The panel will consist of at least 10 TB slides with different degree of TB grading. The panel slides will be procured in the first year of activity with the vision that the NPHL will make their own panels when the TB laboratory at the NPHL is fully operated.

Blinded slide rechecking and training; NPHL will continue both activities through the support from the Global Fund and ICC. NPHL does not require funding from PEPFAR to support these activities.

:Activity 3: The NPHL will procure 1 vehicle, and lab equipment and supplies necessary for the QA TB program.

Activity 4: The NPHL will hire essential staff, including three lab techs, QA/QC manager, a program assistant, and drivers.

The technical assistance and quality assurance activities for the national lab network originally planned for the TBD mechanism Activity 9337 is being reprogrammed to the National Laboratory, who will implment the activities.

SUMMARY: Activities will be carried out to support the enhanced laboratory infrastructure in Haiti with three components: strengthening the capacity of national laboratory network by continuous quality improvement by onsite post-services training of laboratories; post-services training sessions; and maintenance of post-services laboratory curriculum. The primary emphasis areas for these activities are training, quality improvement, infrastructure development, and human resources capacity building. Specific target population includes laboratory workers. IHV will have an active presence of full and part-time US-based laboratory specialists partnered with full-time local hired laboratory personnel throughout the country working in all departments and in Port-au-Prince,

BACKGROUND: This project is part of a larger initiative to build laboratory capacity started in FY05 when University of Maryland's IHV worked with the United States Government (USG) Team to provide a complete package of technical assistance, training (cluster of Differentiation 4 [CD4], and blood chemistry), continuous quality improvement efforts, and provision of kits and commodities. IHV was funded in FY06 directly to continue these activities. In FY 07, an implementing partner to be selected will work in conjunction with the USG Haiti team, and the Ministry of Health (MOH) to provide comprehensive laboratory training and capacity building.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The implementing partner will provide onsite continuous quality improvement and capacity building in 22 ARV laboratories and 40 palliative care and/or Prevention of Mother-to-Child Transmission (PMTCT) laboratories. The on-site technical assistance and training will be provided. A minimum of 3 laboratory staff will be trained in a sustainable manner per each anti-retroviral (ARV) and palliative care laboratory. Laboratories will be assessed for their capacity building and quality improvement needs at the onset of FY07. An individual laboratory plan will be developed for each laboratory focused on each laboratory's specific requirements. Areas of focus for continuous quality improvement and capacity building will be, but are not limited to, proper equipment function and maintenance, quality control and quality assurance techniques, good laboratory practices and blood safety, inventory and forecasting techniques, recordkeeping, and troubleshooting techniques. Focus will be placed on quality improvement and sustainability for quality laboratory technology and techniques. The implementing partner will identify methods for in-country maintenance and service of laboratory equipment. In the event of equipment malfunctions, it will assist laboratories in troubleshooting and coordinate repairs with Haitian Group for the Study of Kaposi's sarcoma and Opportunistic Infections (GHESKIO) lab equipment maintenance engineer, and USG partners for further referral.

Activity 2: The implementing partner will assist in training sessions to be held at the National Public Health Laboratory (NPHL). It will coordinate training timelines and logistics for 15 manual CD4 trainings, and 4 ARV laboratory techniques andl maintain and update laboratory post-services training curriculum as needed. It will translate updates to curriculum into French and distribute to laboratories.

Activity 3: The implementing partner will hire 5 full-time laboratory staff to continue their work and also to train additional local personnel to support the laboratory program, and to hire additional 5 local full-time laboratory staff as Regional Laboratory Staff (RLS), and a full-time in-country project manager to implement the above described activities. Attempts will be made to hire RLSs who reside within each department for sustainability. RLS staff will work full time and to be based at the departmental regional hospitals laboratories and in Port au prince. Technical assistance will be provided to its satellite laboratories within each department. The implementing partner will coordinate with USG to integrate with its strategic information program. It will work closely with the USG Regional Information specialists (RIOs) to collaborate and share current information of the program and share laboratory testing data.

The implementing partner will work closely with USG Haiti and the NPHL training lab staff to provide status reports of laboratories in their department. It will provide logistics for their local staff (cell phones, phone cards, laptops, office supplies, and transportation). It

will coordinate training the regional lab specialists in laboratory-related subjects within the country, utilizing a mentoring program partnering their staff with the local laboratory specialists to be hired in FY07. The training should include Laboratory testing component (HIV serology, special HIV testing, CD4, clinical laboratory testing, and laboratory safety) and laboratory management (quality assurance/quality control [QA/QC], information system, laboratory operation, good laboratory practices [GLP], stock and inventory, and laboratory equipment maintenance). TARGETS: • Improved ARV laboratory capacity (22) in a sustainable manner • Improved palliative care and PMTCT laboratory capacity (40) in a sustainable manner • 150 healthcare personnel trained in CD4 testing • 10 departmental hospitals and Port au Prince laboratories supported by IHV laboratory specialist teams

Table 3.3.13: Program Planning Overview Program Area: Strategic Information Budget Code: HVSI Program Area Code: 13 Total Planned Funding for Program Area: $ 3,640,000.00

Program Area Context:

Haiti's epidemiological and behavioral tracking, as well as the utilization of services, has been historically provided by population-based surveys such the antenatal clinic (ANC) sero-survey, Behavioral Surveillance Survey (BSS) and Demographic and Health Survey (DHS) surveys, and a few research-led activities. The advent of the Global Fund and President's Emergency Plan for AIDS Relief (PEPFAR) has created an immense opportunity for collecting data for measuring the burden of disease, monitoring effectiveness of interventions, and carrying out surveillance of the epidemic.

The strategic information (SI) team has been improving national and program systems to ensure that instruments in place are suited for their multiple purposes, and PEPFAR has emphasized developing capacity for collection of vital and routine statistics. Progress to date includes: • standardized indicators are in use nationwide at all facility-based interventions; • standardized data collection and reporting instruments developed during the scaling-up period are used by most sites; • electronic applications to aggregate facility-based data and manage individual patients have been successfully implemented; • Information Technology (IT) infrastructure has been upgraded so that most participating sites are connected to the internet, enabling them to support the electronic applications necessary to monitor and report on their programs; • increasing availability of data for reporting and analysis; • the surveillance system, dormant for years, is revitalized; and • a new cadre of 32 skilled SI personnel has been hired, trained by l'Institut Haitien de l'Enfant (IHE) and placed at all levels of the health system.

However, significant gaps remain in several areas, including a lack of a standardized system for monitoring key program areas. The system is characterized by great variability in data collection and data quality, and, with the exception of key indicators, each program is unique in what it collects.

The USG Team only has two central-level SI positions. These two positions are supported 5 regional information officers who work with the United States Government (USG) contractors and share the tasks of providing direct support to Haiti's 10 departmental directorates and the 128 participating sites.

USG partners for SI activities include: • The Ministry of Health (MOH) receives support to steer the ""three ones" strategy. • IHE, a local nongovernmental organization (NGO), provides training and assistance in the use of data collection and reporting. IHE also develops and supervises the use of instruments for facility-based activities, aggregates facility-based data for PERPAR reporting, implements the ANC sero-surveys, and collaborates with MACRO on the DHS and with National Alliance of State and Territorial AIDS Directors (NASTAD) for case notification. • Solutions, a local information technology NGO and sub-contractor of IHE, developed the Monitoring and Evaluation Surveillance Interface (MESI), a web-based, aggregate facility-based reporting system, which stores data for facility-based HIV/AIDS services. • International Training and Education Center on HIV (ITECH) developed the paper-based medical record along with the electronic database management system. • John Snow, Inc. (JSI)/ Monitoring and Evaluation to ASsess and Use REsults (MEASURE) is developing a community-based information system, integrating the Health Information System (HIS) for HIV/AIDS into the national Health Management Information System (HMIS), and reinforcing the filing and archiving infrastructure and systems for paper-based data. • Tulane University is helping to develop the monitoring and evaluation (M&E) framework, backstopping efforts for data quality enhancement, and implementing two targeted evaluations. • NASTAD is supporting the revitalization of a case notification system and the development of a

cross-border Haiti/Dominican Republic international health card.

The implementation of the 2005 surveys was delayed for security concerns. The current status of those surveys is: • preliminary results of the 2005 DHS survey have been issued and a final report is scheduled to be released in September 2006; • data is still being collected for the 2005 BSS, and preliminary findings are scheduled for December 2006; • the 2005 ANC sero-survey is underway and preliminary findings are expected in October 2006; • a national health-facility survey to assess HIV/AIDS services in the country is underway with funding from the Global Fund and PEPFAR.

A more accurate estimate of HIV prevalence in Haiti will be computed using two methodologies: (i) Data triangulation using data from the different surveys (DHS, ANC, BSS), and (ii) the EPP (Estimation and Projection Package) using data from the ANC sero-survey. Funding will be earmarked in FY07 to carryout in FY08 the next BSS to ensure that data trends from those surveys are available for analysis.

Data collection and reporting tools for facility-based activities will be rolled out at 30 of HIV treatment and care sites in the country by the end of FY06. A plan has been proposed to develop standardized instruments as well for the community-based activities. Two electronic applications have been developed to facilitate data management and reporting. These include MESI, which will incorporate a module for reporting on community-based activities, and a database management system for the collection of individual data for HIV/AIDS patients. Additionally in FY06, an internet-based project management information system for joint planning and management of all PEPFAR and Global Fund HIV/AIDS projects will be developed and implemented.

In FY07, the USG Team will give priority to the following activities: • enhancement and expansion of facility-based and community-based data collection and reporting systems to reach 100% of the outlets with HIV/AIDS programs in the country through support from PEPFAR, Global Fund and other donors; • development of a comprehensive management information system (MIS) to support the management of drugs and commodities; • reinforcement of data quality through enhanced supervision and more formal, systematic, and periodic comparisons of reported results and primary source data; • increased availability of standard operating procedures and manuals for data collection and reporting; • quality assurance (QA) training of local staff; and • reinforcement of data demand and information use through an assessment of the current situation, training and feedback reports.

There is currently one targeted evaluation study in the pipeline, a situational analysis of commercial sex workers in the zones of major activity in the country. A targeted evaluation is planned for FY07 on anti-retroviral (ARV) drug resistance to assess the implications on treatment regimens in a more mature treatment program and the impact of non-naïve patients who receive irregular supplies of medications from outside sources.

The USG Team will encourage program implementers in FY 07 to constitute M&E units to autonomously manage data; support the hiring of skilled data clerks and disease reporting specialists at participating service outlets; and allow more personnel to participate in M&E training. In addition, the USG Team will help develop and implement an M&E curriculum to be integrated into in-service training for providers of HIV/AIDS services and pursue a cooperative agreement with the MOH to strengthen its lead role in the "three ones." MOH activities will include providing resources to support stakeholder consensus meetings, reinforcement of national database systems, and generation of nationwide reports and analyses to support program implementation. Tulane University will take the lead and work collaboratively with IHE, ITECH, SOLUTION and MEASURE to set up the curriculum for the training sessions.

Program Area Target: Number of local organizations provided with technical assistance for strategic 700 information activities Number of individuals trained in strategic information (includes M&E, 150 surveillance, and/or HMIS)

Table 3.3.13: