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.

Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 5,914,000.00

Program Area Context:

The United States Government (USG) Team is strengthening laboratory facilities to support HIV/AIDS related services in Haiti, in accordance with the MOH's 5-year AIDS strategic plan. The public laboratory network includes the National Public Health Laboratory (NPHL); laboratories at regional departmental hospitals; and laboratories at health care facilities throughout the country. In addition, there are laboratories managed by the private sector, which have well-trained staff and better infrastructure than their public sector counterparts.

Ongoing MOH budget constraints have caused a lack of lab commodities and high quality lab personnel, as well as sub-optimal infrastructure, management, and equipment maintenance in most of Haiti's public laboratories. Improving and sustaining laboratory capacity has been challenging; nevertheless, the USG Team has addressed many of these issues. At the end of 2005, the USG Team was supporting 93 public and private laboratories nationwide either directly or through its implementing partners. This includes support to four reference laboratories; eight departmental hospital laboratories; 51 laboratories (public and private) at referral hospitals; 12 laboratories at healthcare centers; and 18 stand-alone VCT centers.

Improvement of Haiti's laboratory infrastructure is vital to ensuring long-term sustainability of a quality laboratory system with adequate commodities, a reliable electrical supply, and well-trained staff with the ability to maintain lab equipment and generate accurate results for HIV testing, as well as for patients receiving antiretroviral treatment (ART). The USG Team works closely with the Global Fund to avoid duplication of procurement, and also coordinates with the Global Fund-supported National Tuberculosis (TB) Program to integrate HIV testing to TB clinics by trained staff.

Despite continued difficult working conditions in Haiti, to date, the USG Team has accomplished the following:

1) Established a lab supply chain system. The University of Maryland oversees the procurement and International Training and Education Center on HIV (I-TECH) runs the warehouse and distribution program. A national standardized ordering system of lab commodities and a lab test data reporting system was developed. Over 900,000 lab-related items including cluster of differentiation 4 (CD4) and rapid test kits were distributed to those 93 USG-supported sites. 2) Equipped 13 anti-retroviral (ARV) laboratories with inverters and batteries to ensure a constant electrical supply for ARV lab equipment. These labs now operate automated CD4, blood chemistry and hematology instruments. All of the equipment is covered by service maintenance contracts and is protected from power surges. In addition, seven refrigerators and an air-conditioning unit were provided for cold chain storage and to protect lab equipment. 3)Trained nearly 300 lab personnel in HIV rapid test, CD4, blood chemistry and hematology. 4) Assisted the MOH to establish a national rapid HIV testing algorithm, national laboratory quality assurance/quality control (QA/QC) guidelines as well as an External Quality Assurance (EQA) program for proficiency testing (PT) of HIV testing. Results of the HIV EQA PT program are expected in October 2006. 5) Provided assistance to GHESKIO to undertake the biological testing of HIV for the demographic and health survey (DHS+). Over 10,000 individuals were tested for the presence of HIV antibody, and lastly 6) Improved the knowledge and quality of lab tech students for sustainability purposes. I-TECH is now revising and standardizing the curriculum of two medical technology schools. Four faculty members will be trained to teach a refresher laboratory course designed by I-TECH and the University of Washington. In addition, I-TECH developed a lab equipment curriculum for lab tech students and a training course for lab technicians.

Key barriers to strengthening Haiti's laboratory system remain, including a shortage of skilled laboratory personnel, as well as a lack of laboratory space and inadequate infrastructure. Insufficient funds and human resources allocated to improve laboratory infrastructure make progress slow, as do security concerns which have increased the difficulty of traveling within the country.

In FY07, the USG Team will support the following new and continuing activities: 1) Hire 34 lab personnel to provide technical assistance and training (7 ex-patriate at MOH, 9 local-hires at GHESKIO, and 15 local-hires at MOH). 2) Procure and install laboratory equipment for six new ARV sites (CD4, hematology, and blood chemistry), twenty palliative care and Prevention of Mother-to-Child Transmission (PMTCT) sites, 50 VCT and TB/HIV sites, and also for HIV pediatric diagnosis at GHESKIO, Partners In Health (PIH), and the NPHL and also to continue procuring equipment maintenance contracts for 54 ARV lab equipment. 3) Improve laboratory infrastructure by procuring basic equipment for the sites described above including, but are not limited to, gas refrigerators, gas canisters, inverter, batteries, Uninterruptible Power Supply (UPS), and storage cabinets. 4)Procure test kits and supplies for NPHL and train NPHL staff. 5)Provide a unified lab supplies chain system through Partnership of Supply Chain Management (PFSCM) to procure and deliver lab commodities to all USG-supported sites. 6)Install solar electrification system at five ARV or palliative care laboratories. 7)Increase the capacity of laboratory personnel by providing on-site QA/QC supervision and post-service training in HIV rapid test, CD4 count, dried blood spots (DBS) HIV testing, blood chemistry and hematology analysis, QA/QC and laboratory management. 8)Establish a laboratory information system at the NPHL and at three pilot ARV sites, and lastly, 9)Strengthen the capacity of the NPHL by formulating the national lab strategic plan, maintaining its existing QA/QC activities; expanding activity by including dried blood spots HIV antibody testing as a tool for regular QA/QC; establishing an EQA PT for CD4 testing; maintaining the infrastructure of the NPHL; establishing a National Laboratory Training Center; training, and hire and train 10 staff.

At the end of FY07, the USG Team expects the following results: • Increased capacity to provide technical assistance by hiring 34 laboratory staff through partners. • Increased the number of laboratories with capacity to perform ARV lab services including HIV test, and CD4 or lymphocytes tests from 26 to 46. • Increased service capacity at >100 laboratories by having a delivery mechanism to provide continuous laboratory commodities. • Improved infrastructure at 75 laboratories by provision of refrigerators, inverters, batteries and UPS to do rapid testing, CD4 testing and ARV lab services. • Increased number of laboratories using solar energy from 0 to 5. • to provide continuous training in ARV lab services, HIV testing, CD4, hematology, blood chemistry and laboratory management to 600 staff. • to implement laboratory information system in 3-4 laboratories. • to formulate the national lab strategic plan • to implement the National Lab QA Program. • to establish an EQA program for HIV and CD4 testing. • to establish HIV pediatric lab diagnosis at GHESKIO, PIH, and NPHL. • to establish the National Lab Training Center. • to establish routine maintenance of lab equipment.

Program Area Target: Number of tests performed at USG-supported laboratories during the 540,540 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 40 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 600

Table 3.3.12: