INTEGRATED ACTIVITY FLAG: Training, test kits, HIV/AIDS Treatment/ Treatment Services; VCT, Basic

Health Care and Support. This activity is linked to Activity IDs 3918.08, 5472.08, 3912.08, 4348.08,

5412.08, 3902.08 and 12376.08.

SUMMARY: The Ministry of Health will provide field support to 28 public sites for the provision of a full

package of PMTCT services. The Ministry will also address the problem of PMTCT not being able to retain

positive women enrolled and put them on prophylaxis with their babies, by instilling new practices in

services provided to pregnant women in general during their pregnancy and labor, and in the way that

positive women and their families are assisted and taken care of. Focus will be on expanding some of the

best practices learnt in integrating PMTCT care in maternal and child care services and inculcating them to

providers of ANC and maternity care services through training. Indeed, PMTCT training has so far been

limited to classroom session and deal narrowly with the realities and organization of prenatal and maternity

care. The Emphasis areas for this component are: (i) community mobilization, (ii) human resources as more

tasks will be shifted from health care personnel to social workers and lay-personnel (iii) development of

network linkages, as concerted efforts will be made to reach out to Traditional Birth attendants( TBA). The

primary targets of this intervention are the 70,000 pregnant women, which on average attend services at the

targeted facilities. These sites are spread across the 10 geographical department of the country and include

two major teaching hospitals, 9 referral regional hospitals, and various community hospitals. This year the

Ministry will support all public sites that used to be funded under other mechanisms. (Justinien-Cap, HIC-

Cayes, St Antoine-Jeremie, St Michel-Sud Est, Gonaives-Artibonite, Petit Goave- Ouest)

BACKGROUND: About 25 public health facilities currently provide services that range from VCT to

antiretroviral combination treatment. The staffing situation of many of these facilities was improved through

resources provided under PEPFAR in FY05, FY06 and FY07. However several factors that in general

impact negatively motherhood and delivery practices in Haiti continue to interfere with the monitoring of

positive pregnant women and their appropriate uptake of ARV prophylaxis. Although the infusion of

resources has considerably increased the testing among pregnant women (17,777 women from Oct 06 to

May 07) and has helped identify more positive women, the proportion which completed their ARV regimen

prophylaxis has not grown at the same pace. The program needs to continue its efforts to address some of

the structural barriers which hamper retention of women, and more specifically put in place mechanism to:

(i) entice pregnant women to make follow up visits after their initial visits, as in Haiti large proportion of

pregnant women tend to drop out of follow up after their first ANC visit (ii) create an environment conducive

to the adoption by pregnant women of buddy companions (accompagnateurs) to supervise the uptake of

drugs at home, as this has been the case for the ARV treatment program. The disclosure of their positive

status during pregnancy renders women more vulnerable and susceptible to stigma and rejection by their

family and their partners. (iii) create more linkages with communities by allowing PMTCT sites to recruit

more community health agents or work closer with TBAs in order to monitor and track pregnant women.

Currently the few community health agents hired at the sites are swamped by the services to be provided to

all patient sin care and have no time to address specific needs of PMTCT clients (iv) encourage women to

deliver at the health facilities not only by subsidizing delivery costs but also by offering transit shelters to

their relatives, as evidence is pointing out that convenience of family has a huge sway over the decision of

whether or not pregnant women will be taken to health facility for delivery. (v) Create better linkages

between ANC and maternity wards so that information could flow between the two wards for continuum of

care for pregnant women (vi) create conditions to access systematically partners of positive pregnant

women and provide them with counseling and care when needed.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1. Field support to 28 PMTCT sites including 25 existing and 3 new to enable them to provide a full

package of services including (i) Counseling and testing to all pregnant women both at ANC and maternity

wards (ii) STI management using a syndromic approach iii) Reproductive health services, particularly family

planning counseling for HIV positive individuals and the promotion of condoms; (iii) Psychosocial support

through individual and family counseling, mainly by social workers and community health workers and

through the setting up of support groups 6) Safe obstetric practices 7) ARV prophylaxis for women and their

babies 4) Case management of HIV positive pregnant women including clinical and biological monitoring.

The funding will support: (i) hiring of more nurse midwives, (ii) hiring of dedicated social workers and

community health agents for PMTCT, especially at large sites where undivided attention are needed to

address needs of pregnant women and their babies (iii) acquisition of educational materials and support

equipment to facilitate educational activities (iv) support to some operational costs incurred by facilities (iv)

acquisition of equipment for delivery. At community level, the programs will be supported by the staff of

newly designed Palliative Care institutions for the provision of psycho-social support, increase of adherence

to prophylaxis and referrals of both HIV+ pregnant women/mothers and their infants.

Activity 2: The creation of a retention package, which includes: (i) subsidy for cost of follow-up visits and

hospital delivery (ii) maintenance of women support groups (iii) temporary shelters for parents

accompanying pregnant women to centers. Most of these activities had been enlisted in previous planning

exercise but got barely carried out, because they'd been lump into the overall package provided to the sites

and engulfed by other competing needs. This year, the funding destined to these activities will be provided

as a hard earmark, and spending executed by the dedicated PMTCT social workers to ensure that the

beneficiaries' needs prevail.

Activity 3: Development of an integrated PMTCT (+) package model. This activity implies the

implementation of an integrated family-centered PMTCT (+) approach at a University teaching hospital,

Maternite, Isaie Jeanty. The approach will consist in offering HIV/AIDS partner referral services, couple

counseling and pediatric care to women who test positive. Temporary accommodation will also be offered to

relatives accompanying pregnant women for delivery. The teaching capacity of this hospital will be used to

organize practicum sessions for in-service PMTCT training and for nurse midwives schools when covering

their PMTCT module. This component will receive technical assistance of ITECH, which also supports both

in-service and pre-service training.

Activity 4 : Mobile Quality assurance/quality control and mentoring. QA/QC for PMTCT will be decentralized

at 10 departmental directorates. Using senior staff at the Centers of Excellence of the department, the

departmental directorates will put in a system for carry out supervision visits at the peripheral sites to control

and ensure quality of the services, and provide mentoring at the centers of excellence to staff coming from

the peripheral sites. This practice had been initiated in FY07, but will be institutionalized under the technical

backstopping of ITECH. In addition mobile VCT teams will be deployed at various health departments in

order to provide CT services at CRS and World Vision food security ante-natal clinics.

Targets - September 2009:

- Number of service outlets providing the minimum package of PMTCT services according to Haitian and/or

international standards: 28

- Number of pregnant women who received HIV counseling and testing for PMTCT and received their test

Activity Narrative: results: 20,00

- Number of pregnant women provided with a complete course of antiretroviral prophylaxis in a PMTCT

setting: 700

- Number of health workers trained in the provision of PMTCT services according to national and

international standards: 80

Integrated Activity: This activity is linked to Activity IDs 3851.08,3918.08, 3912.08, 4348.08, 5412.08,

3902.08 and 12376.08.

SUMMARY. The Ministry of Health (MOH) will sustain the provision of a basic package of palliative care

services within a network of 30 public sites including dispensaries, community hospitals, departmental

hospitals and University Hospital spread across the 10 geographical departments of the country. In Fiscal

Year (FY) 2008 efforts will be devoted to: (i) ensuring that the ratio of clinical personnel per patient is

adequate, (ii) hiring more social workers and community health workers (iii) creating more people living with

HIV/AIDS (PLWHA) supports groups, and (iv) continuing to subsidize patients for hidden costs linked to the

access to services. The program will focus on: (i) expanding capacity of palliative care sites to perform

follow up of stable patients on anti-retroviral (ARV) services, (ii) developing a post graduate nurse

practitioner program, and (iii) creating at the regional level capacity to provide training in basic community

care and support to community health workers. The emphasis areas for this component are: (i) community

mobilization and, (ii) human resource development. The primary targets are the 15,000 patients expected to

be served by this network in FY 2008.

BACKGROUND. The President's Emergency Plan for AIDS Relief (PEPFAR) funds a network of public

health sites through a variety of funding mechanisms. In FY 2006 and FY 2007, many of these sites have

become voluntary counseling and testing (VCT) sites though United States Government (USG) support.

The 25 sites currently functional out the 30 planned for FY 2007 have tested 45,466 patients from October

2006 to May 2007 and have enrolled 6,958 patients over two years of providing services. One of the

challenges to the program has been retaining positive patients after they are screened.

For instance 58% of the 4,665 patients who tested positive from October 2006 to May 2007 have been

enrolled into care. This suggests interventions are needed not only at the site level, but also at a broader

level to remove some of the structural constraints that affect the provision of care, generally. Indeed, the

fact that providers of care, so far, remain restricted only to physicians (who are in short supply) limit the

number of providers available to provide care. The re-introduction of community health agents in the public

sector, after more than 30 years, has provided the sites with increased capacity to reach patients within

their families and their communities. However, there are very few places where community health agents

can receive training and acquire the competencies needed to do their job. The Ministry of Health (MOH) is

ready to take the necessary steps in FY 2008 to address those structural problems by, for instance,

initiating a nurse practitioner program to prepare nurses to head services at the peripheral sites, and by

creating capacity to train health workers in several departments.

ACTIVITIES AND EXPECTED RESULTS.

Activity 1: Provision of field support to 30 sites to enhance their clinic-based activities for management of

OIs through appropriate diagnosis and treatment, and organization of nutrition and psychological support

services. These sites include: three large university hospitals, nine geographical departmental hospitals,

and multiple community hospitals and health centers. The sites are expected to provide services to a

network of 15,000 patients. Funding will cover the cost for a trained multidisciplinary team composed of

physicians (only for large sites), dedicated nurses, social workers, laboratory technicians, and community

health workers. The funding will also support basic office and medical equipment, supplies, and utilities

such as water, communication, and power. Some refurbishing will be allowed especially to enhance

laboratory capacity, drug storage, and clinical management.

Activity2: PLWHA retention package: Across the board, the attrition of patients enrolled in care remained

fairly high (about 40%). The program this year will try to address some of the contributing factors in a

discrete fashion by earmarking funding destined to these activities so that they are not used for other

priorities at the facilities. Social workers, who are directly in contact with patients, will trigger the expenses.

This component will cover the: (i) the multiplication of PLWHA support groups so that at least 80% of

patients can join those groups. It has been noted that participation in support groups has improved patient

adherence to treatment as well as their acceptance of the disease. However, limited resources has only

allowed each site to constitute, on average, three groups of 25 patients, (ii) subsidies for travel cost for

patients and their accompagnateurs when they visit the clinic, and (iii) subsidies for additional costs related

to laboratory and medical procedures not covered directly by the program, but which are necessary.

Activity 3: Home based care: MSPP will increase the number of community health workers to

accommodate a scale-up of care to patients at each of the sites within its network. The community workers

will be in charge of tracking patients (including pregnant women enrolled in PMTCT and infected and

exposed children), provide at home adherence support, health education on best health and nutrition

practices, counseling for positive behavior, distribution of care and preventive commodities such as

condom, ORS, and pain medications, according to the guidelines, and to make appropriate referrals.

Appropriate training will be provided to the community workers on symptom recognition, and syndromic

treatment, particularly when they have patients experiencing health or psychosocial problems.

Activity 4: Development of a post graduate nurse practitioner training program. Currently nurses are the

most vital and the most stable element of the program with functions varying from site managers,

counselors, nursing care, to drug dispensers. The majority live in the communities where they work and

represent six to eight times the number of physicians available nationwide. Having nurses trained as

practitioners would rapidly increase access to services. There is also need to improve skills in nutrition

assessment and management of malnourished PLWHA. Nurses would not only provide palliative care

services, but would also provide primary clinical management of stable ARV patients under the oversight of

their referral centers. This will increase the operational capacity of the ARV sites, which are overburdened

currently, to recruit and treat more patients. The curriculum of the course is in development by ITECH and

the Ministry of Health would support training logistics, which would take place at two of the university

hospitals: Hopital Universaire d'Etat de haiti (HUEH) and Hopital La Paix. One hundred nurses would be

trained at an average cost of US $ 800 per nurse. A total of $800,000 would cover living stipends of the

fellows.

Activity 5: Development of capacity at the regional level to train community health workers. Community

health workers (CHW), under the supervision of the social worker, serve as the principal liaison between the

health facility and PLWHA. They usually conduct home visits of PLWHA, ensure adherence to drug

regimens, provide advice on personal care, identify or help develop self-support groups to which PLWHAs

could be enrolled, help plan community meetings to dispel myths about HIV and combat stigma, refer

PLWHAs needing acute care to the nearest health facility, and refer PLHWAs in need of economic or

nutritional support to the appropriate agency. Initially, when there were only two training models on which to

build—GHESKIO and PIH—training was limited. However, there are now centers of excellence in each

Activity Narrative: departmental directorate, and it is possible to tap into existing teaching capacities and train community

health agents locally. Four hundred CHWs would be trained.

Targets.

Number of service outlets providing HIV-related care palliative care: 30

Number of individuals provided with HIV-related care and support (excluding TB): 12,000

Number of individuals trained to provide HIV-related palliative care: 500

Emphasis areas:

Development of networks/linkages/Referral systems: 70%

Linkages with other sectors/initiatives: 20%

Training: 10%

Integrated Activity: This activity is linked to Activity IDs 3851.08, 5472.08, 3912.08, 4348.08, 5412.08,

3902.08 and 3918.08.

SUMMARY: With the President's Emergency Plan for Aids Relief (PEPFAR) Fiscal Year (FY) 2008

resources, the Ministry of Health (MOH) will reinforce and expand the tuberculosis (TB) HIV program by

improving the policy environment in order to strengthen existing programmatic activities and to address

some critical gaps such as TB resistance, TB infection control, and integration of TB/HIV in pediatric care

(see program narrative). Through these changes, the MOH will improve its capacity to coordinate the

TB/HIV program at central and departmental levels in coordination with other key TB lead non-

governmental organizations (NGOs). The MOH will also focus on expanding TB/HIV activities in its network

of pubic sites. These resources will be integrated with those allocated by the United States Government

(USG) to the MOH to expand counseling and testing (CT), PMTCT, palliative care, and ARV services at the

same sites and to strengthen policies. This program is built on Global Fund to Fight AIDS, Tuberculosis and

Malaria (GFATM) resources allocated to support the TB/DOTS program.

BACKGROUND

The MOH is the primary regulatory entity for health care service delivery in Haiti, including HIV and TB

services. It is also the most important provider of health services, with a network of dispensaries, community

hospitals, regional departmental hospitals, and university hospitals. Most of these facilities serve big cities

and the poorest segment of the population who are at higher risk for HIV and TB. With support from

PEPFAR, counseling and testing (CT), and care and treatment services have been implemented in a

network of about 20 public facilities, including the two major university teaching hospitals where pre-service

training for HIV care and treatment has been integrated. All of these sites have been integrated with TB/HIV

with emphasis on TB screening, prophylaxis, and treatment for HIV positive patients.

For the TB program, the MOH, despite its chronic structural weaknesses, has always played a productive

leadership role in management and coordination with the support of the lead TB NGOs such as

International Child Care, (ICC) CARE, and Centre Pour Le Développement et la Santé (CDS). The NGOs

have a TB coordination unit at the central level that has a representative in each region of the country and is

overseeing program planning, implementation, and monitoring. Recently this unit has been reinforced with a

TB/VIH coordinator. Over the last two years, the United States Government has progressively taken steps

to reinforce the regulatory and coordination roles of the MOH in HIV activities by providing resources to

strengthen the management unit of HIV, epidemiology at both central and departmental levels. This year a

team of data managers and HIV program coordinators has been hired in each department to reinforce

departmental coordination.

With FY 2008 resources, MSPP will continue to integrate and expand though this network's TB screening,

prophylaxis, and treatment. Additional focus will be put on reinforcing the MOH leadership in TB/HIV

program management at central and departmental level in integration with other PEPFAR funded activities

and in coordination with the GFATM.

EXPECTED RESULTS AND ACTIVITIES

ACTIVITY 1: The MOH will reinforce the existing 20 sites and 10 new sites (to be added next year) of its

network to perform TB screening, prophylaxis, and treatment for HIV positive individuals. Next year, MSPP

will focus on HIV positive children as pediatric care in being expanded through this network. TB Infection

control measures as well as TB drug resistance monitoring will be implemented in this network according to

national norms and protocols. Resources will be used to build human capacity, reinforce infrastructure,

including laboratory (based on needs assessment) and to ensure adequate provision of PPD test and

related commodities and INH for prophylaxis (see SCMS activity narrative). The program will train health

professionals at Siguenau Hospital in the hospital's pursuit to become a TB/HIV center of excellence (see

GHESKIO activity narrative). Building on activities planned this year, MOH will continue to expand x-ray

capacity in the network of public sites by providing equipment, related materials and commodities and by

reinforcing human resources in order to improve TB screening. This will complement sputum smear

diagnosis capacity implemented at all TB sites through the TB/DOTS program financed by the GFATM.

ACTIVITY 2: MSPP will use PEPFAR resources to strengthen human resources and logistics at the TB

central unit and departmental levels to work with other key lead TB NGOs—International Child Care, CARE,

Centre Pour Le Développement et la Santé, and Groupe Haitien d'Etude du Darcome de Kaposi et des

Infections Opportunistes—in order to continue strengthening the coordination and monitoring of the TB/HIV

program. Needs assessment will be done at each department to determine gaps in human and logistics

capacity. National tools for TB/HIV monitoring will be developed and integrated for HIV care and treatment

that is being developed this year.

ACTIVITY 3: In coordination with leading NGOs, the MOH will take a lead role in developing and/or

updating appropriate norms, protocols, guidelines, and training tools for TB/HIV with emphasis on TB

infection control, TB HIV pediatric care, and monitoring TB drug resistance. PEPFAR resources will used in

integration with those from the GFATM to support necessary workshops, international technical support,

multiplication, and dissemination of these documents.

ACTIVITY 4: The MOH will also take the lead through its central TB unit and in coordination with the

National Reference Laboratory to elaborate and implement a national plan for monitoring TB drug

resistance. Resources will be allocated to train human resources, manage specimens to refer to specialized

laboratories as well as for tracking and referral of patients with suspected TB drug resistance.

ACTIVITY 5: The MOH will ensure linkages of this TB/HIV program to other HIV related activities

particularly care and treatment and community palliative care programs that are being reinforced.

Targets:

Number of sites providing TB/HIV: 30

Number of professionals trained in TB/HIV: 50

Number of HIV patients screened for TB: 10,000 (10% children)

Number of HIV patients treated for TB: 500

Number of HIV patients on INH prophylaxis: 1,000

Integrated Activity: This activity is linked to Activity IDs 3851.08, 5472.08, 3912.08, 4348.08, 5412.08,

3918.08 and 12376.08.

Activity Narrative:

SUMMARY: With Fiscal Year (FY) 2008 resources, the United States Government (USG) plans to

strengthen the capacity of the Ministry of Health (MOH) and continue to expand counseling and testing (CT)

services to patients seen at hospitals using a provider-oriented approach to optimize the potential for testing

patients. Currently, MoH as 25 active sites and is expected to have 30 sites by the end of FY2007. This

support will enable expansion to 40 sites. Particular consideration will be given to: (i) training a generation of

lay-counselors to counsel at public health sites so that more people can get access to counseling services,

(ii) providing health center users more opportunities for exposure to prevention messages, especially those

that test negative, (iii) decentralizing capacity to carry out training and quality assurance and quality control

(QA/QC) for counseling and testing at the department level. The emphasis areas for this component are: (i)

community mobilization and, (ii) human resources as some tasks will be shifted from health care personnel

to lay-counselors. The primary targets are the 700,000 users of services that on average attend these

facilities each year. These sites are spread across the 10 geographical departments of the country and

includes three major teaching hospitals, 10 referral regional hospitals and various community hospitals

BACKGROUND

The MOH is the prime regulatory entity for health care service delivery in Haiti, including HIV services. It is

also the most important provider of health services with a network of dispensaries, community hospitals,

regional departmental hospitals and three university hospitals. During FY 2007, many of these hospitals and

health centers have established CT services with USG support. Currently 25 of the main public sites receive

this support through a direct cooperative agreement with the MOH managed by an executing unit under the

supervision of the central level, five other major department hospitals receive support through other USG

mechanisms. This year, all public sites will receive funding under the MoH cooperative agreement as this

mechanism has matured and shown capacity to play the fiduciary role for the entire network. From October

2006 to May 2007, this network of public sites have tested 45,466 people and detected 4,068 HIV +

patients.

For the most part, counseling services at the health institutions have been provided by health care

providers, thus considerably limiting access. This year the task will be shared with lay counselors at the

peripheral sites where the work load of health care providers is enormous. To increase access to training,

more capacity will be created at the regional level. The lack of logistics for training at the local level has

limited capacity to train personnel at all sites in counseling activities.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Expansion of counseling and testing services to 10 new sites. This will be done as part of an

effort to fill gaps in coverage identified by the departmental directorates, especially in the West Department

where there are very few sites in the region sharing borders with the Dominican Republic (Fonds Parisein,

Ghanthier, Thomazeau). Moreover, the departmental directorates are currently engaged, with the help of

the USG team, in a process of assessing coverage and laying out departmental plans. This has led to the

identification of new sites with high potential. We estimate that an initial investment of US $70,000 per site

for a total of $700,000 could enable the new sites to: (i) carry out needed renovations, (ii) procure office and

lab equipment, (iii) ensure promotion of services within the institutions and in the neighboring communities,

(iv) procure equipment and materials for promotional activities (TV, VCR), (v) hire lay-counselors,

phlebotomists and community health agents, (vi) procure critical utilities such as gas for refrigerators, and

(vi) organize post tests clubs and PLWA support groups. This does not include the cost of test kits.

Activity 2: Field support to CT services at 30 existing sites, including six public sites currently funded under

other mechanisms (Justinien-Cap, HIC-Cayes, St Antoine-Jeremie, St Michel-Sud Est, Gonaives-Artibonite,

Petit Goave- Ouest). This activity will emphasize fully integrating CT into routine clinical services offered to

all patients and providing more partner referral services as well as couple and family counseling. We will

continue to carry out pre- and post-test counseling at various wards, and test results communicated the

same day. Funding will cover salaries of current counselors and phlebotomists, hire lay counselors, and

procure critical utilities. Activity 3: In-service training and QA/QC for counseling at the departmental level. In

FY 2006 and FY 2007 several resource persons from various departments completed their training of

trainers, using the teach-back method. However, further iterations of the expected cascade never took

place because the resources to sustain the logistics for the sessions were not planned. By allocating US

$150,000 to each of the 10 departments, for a total of US $ 1,500,000, it will possible to: (i) equip existing

facilities, such as the nursing school in the Southern Department and Grande Anse or the Department in the

South East to hold regional training sessions. Some renovation might be needed to support rapid test

training at those locations (e.g. adding sinks, counters), (ii) provide available training materials at the

regional level, (iii) support the logistics of theoretical and practicum sessions and, (iv) support the cost of

QA/QC activities that the department directorates will carry out throughout the year. Training will be directed

at health centers' staff, residents in transit in the departments and lay counselors. ITECH/INHSAC will

provide technical assistance to the departments to strengthen the training and QA/QC activities of the

department (see ITECH proposal on Counseling and Testing).

EMPHASIS AREAS:

Community mobilization /Participation 20%-50%

Training 20%-50%

Quality assurance/quality improvement/supportive supervision 10%-50%

Development of network/linkages/referral systems 10%-50%

Information/education/communication 10%-50%

TARGETS:

Number of service outlets providing counseling and testing according to national or international standards

= 40

- Number of individuals who received counseling and testing for HIV and received their test results =

47,000

- Nb of individuals trained = 200

TARGET POPULATIONS:

Health care workers

People affected by HIV/AIDS

HIV positive pregnant women

HIV positive infants and children

Special populations

COVERAGE AREAS: All geographic regions receiving PEPFAR support for HIV care and treatment

Activity Narrative: services.

SUMMARY: Through a cooperative agreement (CoAg) with the Ministry of Health (MOH), the United States

Government (USG) team in Haiti will support the scale up of on-going ARV services at the State University

Teaching Hospital (HUEH) and five other major public sites: La Paix Hospital (a new university teaching

hospital) serving the large commune of Delmas, Sainte Therese Hospital in the Nippes Regional

Department, Immaculee Conception Hospital and Jean Rabel Hospital in the North West Regional

Department, and Isaie Jeanty Hospital (another University teaching hospital) in the West Department. The

major focus of this activity will be to support the overall service organization at these sites to deliver quality

treatment services. These resources will continue to be integrated with those allocated through International

Training and Education Center on HIV (I-TECH) to support technical assistance and clinical mentoring at

the HUEH and Isaie Jeanty as well as with those allocated through the MOH to support CT, PMTCT, and

palliative care services at the four targeted public sites. In addition, Isaie Jeanty, HUEH and La Paix, as

University Teaching Hospitals, will serve as venues to train interns and residents on HIV treatment. With

these resources, the MOH will directly manage six of the forty-one anti-retroviral (ARV) sites which will be in

place by the end of September 2008. The other thirty-five sites are being supported through the Haitian

Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Partners in Health

(PIH), AIDS/Relief Consortium, Management Science for Health (MSH), and I-TECH. MOH will continue to

be supported to play its critical role in creating a good policy environment and coordinator of the program.

BACKGROUND: Over the last three years, the publicly-managed sites have increasingly become the major

focus of the USG effort to expand clinical and ARV services. Most of these sites serve large and needy high

-risk populations in the urban and metropolitan area. The major departmental hospitals have been

supported through GHESKIO, PIH and, more recently AIDS/Relief, to deliver all clinic-based services (CT,

PMTCT, clinical care and anti-retroviral treatment [ART]) in integration with other support from the Global

Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Many deficiencies in these hospitals led to multiple

challenges to the implementation of services at these public sites; however, the USG was able to allocate

the necessary resources to make this approach successful.

Over the last two years, the USG has provided resources directly to the MOH through a cooperative

agreement (CoAG) with CDC to implement ARV services in six publicly managed sites, including HUEH, the

biggest university teaching hospital in the country. These resources have been complementary with other

resources provided to the MOH to support a network of 20 institutions to provide integrated CT, PMTCT,

TB/HIV and basic care.

Because of the delay in receiving FY 2007 resources, most activities planned this year to strengthen the

MOH network have just begun. This includes the launch of 10 new palliative care sites (for a total of 20),

and the expansion of ARV services to Isaie Jeanty, one of the largest maternity wards in the country. The

new launch of ARV services in the four other publicly managed hospitals are on track as planned. These

include: Sainte Therese and Immaculee Conception/Port-de-Paix hospitals, which are departmental

hospitals located in departments with the highest prevalence of HIV; Jean Rabel Hospital, which is located

in the very hard-to-reach North West Regional Department and is in need of more accessible ARV

services ;and La Paix Hospital serving Delmas and Tabarre communes. HUEH, in spite of many

challenges, including numerous personnel strikes that has jeopardized its ability to provide services, was

able to commence delivering ARV services. This facility has also benefited from resources from GFATM

which was used to support expansion of counseling and community outreach activities. HUEH is enrolling a

mean of 30 ARV patients each month. In coordination with I-TECH, the MOH has recently launched a new

in-service training center at HUEH that will complement GHESKIO and PIH's ARV service delivery training

capacity.

MOH has also has support to reinforce its logistic and human capacity at central and departmental levels to

play a greater role in coordinating the program. Through HIVQUAL and CDC, and with the support of major

stakeholders, the MOH has started to strengthen the national system of QA/QI. MOH plans to use experts

from HUEH and the regional centers of excellence to be the technical arms through which QA/QI activities

could be implemented .

FY 2008 resources will be used to maintain all these activities with particular emphasis on rolling out a good

QA/QI system. MOH will ensure that national norms and procedures are followed for the delivery of

continuous quality of HIV treatment across all the networks.

ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will continue to build on resources

allocated for other program activities such as CT, PMTCT, and palliative care, to enhance infrastructure,

provide medical equipment and materials (including laboratory), hire additional clinical personnel

(physicians, nurses, psychologists, counselors and social workers), and support additional community

personnel to expand ARV services at HUEH and at other ARV sites in the network. Training and refresher

courses will be realized for the personnel of the MOH network at HUEH . Resources will be used to

continue supporting the current successful models of treatment which are based on high-quality clinical and

lab assessments of patients to determine ARV eligibility; high-quality counseling and education of patients,

family members and "accompagnateurs;" and on a high-quality pharmacy and community support plan to

ensure adherence to treatment.

Activity 2: The MOH will continue to build on resources available through I-TECH for clinical mentoring,

training and technical assistance to reinforce the teaching of HIV treatment protocols for interns and

residents at the three teaching hospitals--HUEH and Isaie Jeanty and La Paix. MOH will provide resources

to enhance training capacity and support logistic equipment and materials costs. Continuing education

sessions will be held for the staff to keep them abreast of new developments in ART care relevant to their

functions.

Activity 3: Strengthen referral linkages. In the different areas where the five MOH sites are located, there

are a number of private and public hospitals offering voluntary counseling and testing (VCT) services. The

MOH will establish a referral system between these peripheral sites and the ARV sites to ensure a

continuum of care to patients. In addition, these ARV sites will be linked to the community-based-

organizations (CBO) and People living with HIV/AIDS (PLWHA) support groups to provide integrated

community support for patients enrolled in treatment.

Activity 4: At the MOH Central Office, a multidisciplinary team (clinician, counselor, social worker and lab

Activity Narrative: technician) will be established to coordinate the program. With the technical support of CDC and HIVQUAL,

MOH will build his capacity to expand the national system of QA/QI that will be launched this year. Funding

will also be used to disseminate the national treatment guidelines that were updated this year.

Targets:

Number of interns and residents trained (pre-service training): 350

Number of health professionals trained (in service training): 100

Number of PLWA actively enrolled in ARV: 2300

Integrated Activity: This activity is linked to Activity IDs 3851.08, 5472.08, 3912.08, 4348.08, 5412.08,

3902.08 and 12376.08.

SUMMARY:

Funds will be used to provide sufficient laboratory working bench space and purchase equipment needed

for improvement of laboratory infrastructure,. A functional laboratory is critical to support persons living with

HIV/AIDS (PLWHAs). Laboratory technicians will also be hired and trained.

BACKGROUND:

ACTIVITES AND EXPECTED RESULTS:

The MSPP National Plan proposes to carry out the following activities activity in this Program Area.

ACTIVITY 1: The MSPP National Plan will prepare 10 laboratories within its network to provide basic

palliative care and/or ARV laboratory services for PLWHAs. With the addition of new laboratory testing

methods (eg CD4 counts, hematology or clinical chemistry tesing, either manual or automated) certain

laboratory systems requirements have to be met. Usng local companies, MSPP will procure and install

basic items essential for improving laboratory infrastructure including laboratory bench space, working hand

-wash basin, office space for lab management, storage, and blood collection area. The MSPP National Plan

will procure, install and secure sets of inverters and batteries ensuring constant electrical supply to the

laboratories as well as a water tank and water pump to ensure constant water supply. The MSPP National

Plan will subcontract local companies to procure gas refrigerators, provide gas tanks, maintain and service

gas refrigerators at the laboratories to make sure that refrigerators are operating well in order to keep

essential CD4 and other laboratory test kits cold.

ACTIVITY 2: The MSPP National Plan will hire additional lab for those ARV laboratories (1 per site) in order

to carry out extra laboratory testing work load for people living with HIV/AIDS. The hired lab technicians will

be trained by the National Public Health Laboratory staff for laboratory testing, QA/QC, good lab practices

and lab management. There will be no cost for training since the NPHL will cover the expenses of training

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of laboratory

services in order to identify HIV positive persons and increase the number of persons receiving ARV

services.

EMPHASIS AREAS:

Infrastructure51%-100%

Human capacity development10%-50%

TARGETS:

3 Lab technicians hired

10 laboratories to perform HIV-testing and CD4

10 laboratories improved its infrastructure

TARGET POPULATIONS:

People living with HIV/AIDS

Laboratory Workers

COVERAGE AREAS: National

SUMMARY: The purpose of this activity is to help materialize the "three ones" concept by capacitating the

Ministry of Health (MOH) to: (i) implement the national monitoring and evaluation (M&E) framework; (ii)

consolidate the HIV/AIDS information system into the Health Management Information System (HMIS); (iii)

support the production and rolling out of standardized paper-based forms and registers both for facility and

non-facility activities; (iv) assume a greater role in data validation and processing; (v) manage and process

data, as well as monitor performance in all HIV/AIDS program areas; (vi) expand and maintain information

technology (IT) infrastructure that currently links the different levels of the system (sites, department and

central levels); (vii) expand the use of electronic databases such as the Monitoring Evaluation Surveillance

Interface (MESI) and electronic medical records (EMR) and; (vii) coordinate and consolidate all monitoring

and evaluation (M&E) training. The emphasis areas for this activity are: HMIS, IT, and HIV surveillance. The

primary beneficiaries are MOH officials and staff, donors, service providers, and sites' personnel.

BACKGROUND: Haiti's health care system is divided into three sectors: public facilities, accounting for

about 40% of service delivery; private not-for-profit and mixed facilities and programs, accounting for

another 40% and; private for-profit providers (medical clinics and hospitals) accounting for the remaining

20%. In addition to its role as service provider, the MOH governs and regulates the system through several

central departments in charge of standards, supervision, quality control and strategic planning. Within the

MOH, the units which play the most prominent role with regard to strategic information are: (i) the Unité de

Coordination de la Lutte contre les IST/VIH/SIDA (UCC), responsible for planning, monitoring and oversight

of all HIV activities in the country; (ii) the Department of Epidemiology (DELR), in charge of surveillance,

control, regulation, and integration of priority programs and; (iii) the departmental directorates (DDs)

responsible for operations and oversight of field activities.

Through a cooperative agreement (CoAg) with the MOH, funding has been provided by the President's

Emergency Plan for AIDS Relief (PEPFAR) in Fiscal Year (FY) 2005 through FY 2007 and has allowed: (i)

greater access to data by DDs and the central level through the electronic applications developed (MESI

and EMR); (ii) reinforcement of the M&E structures at the DDs, where dedicated M&E staff has been hired;

(iii) establishment of an information technology ( IT) infrastructure comprised of national and regional

servers allowing the local hosting of data; (iv) establishment of a dependable system for distribution of

paper based materials (Forms and registers) utilized for data collection and reporting; (v) revitalization of a

case notification system at pilot sites that has paved the way for expanded surveillance activities; and (vi)

setting up of a national M&E course for HIV/AIDS professionals with the help of Tulane University, (vi)

consolidation of all M&E training under the umbrella of the MOH and; (vii) an increase in the number the

field visits carried out by the departments and the UCC.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: M&E framework and Consensus building: The MOH will continue to conduct consensus-building

activities among all stakeholders (donors, MOH officials, and service providers) to develop a national health

information system. To build consensus, the MOH will maintain and support the M&E cluster by calling

regular cluster meetings, keep minutes of the meetings, and provide adequate follow-up to all meeting. The

MOH will organize a national M&E framework conference focusing on the steps to materialize the

framework. US funding will cover the logistics of the multiple meetings and the workshop, the acquisition of

services of a consultant to handle the details and the production and dissemination of the M&E framework.

Activity 2: Producing and distributing data collection and reporting tools and registers. Various tools have

been designed or adapted for clinical care and community services. Most of these tools, developed with

United State Government support, have been extensively tested in the field. The MOH has in place a

functional distribution system which has reduced the frequency of out of stock forms experienced in the

past. The system functions with a central warehouse at the UCCC and regional hubs at the DDs. The MOH

will continue to ensure seamless supplies to the sites and the community-based activity outlets. The tools to

be produced and distributed include: voluntary counseling and testing (VCT) and preventing mother to child

transmission (PMTCT) registers and reporting forms, patients charts (intake, follow up, laboratory,

pharmacy, and discontinuation forms), pre anti-retroviral (ARV) and ARV registers, and community based

registers and reporting forms (prevention, OVC, and palliative care). USG funds will be used to reinforce

storage capacity at the UCC and the 10 DDs, produce the multiple forms and registers and cover the cost of

handling and shipping.

Activity 3: Expanding and enhancing Information Technology( IT) infrastructure by (i) providing hubs and

network equipment, (ii) ensuring protection of existing assets through installation of UPS and inverters, and

(iii) supporting basic computer training for field staff. With an objective to take advantage of the possibility

offered in IT and facilitate processing and sharing of information, PEPFAR and other donors have

supported, through different mechanisms, the procurement and installation of IT equipment. The results

have been remarkable. Monthly data are now available for 98% of implementing partners. As new sites are

launched and as the information system for community services is rolled out, efforts will concentrate in FY

2008 on: (i) equipping the new sites and reinforcing IT capacity for the community-based partners and, (ii)

expanding training in basic computer skills and computer maintenance for M&E field staff. The MOH has

also initiated in FY 2007 the creation of an intranet, which will be expanded in FY 2008. PEPFAR funds will

(i) cover the cost of training for personnel in 150 sites and 100 collaborating community based organizations

(CBO) implementing non facility-based program, (ii) procure and install IT equipment and accessories, and

(iii) reinforce the intranet.

Activity 4: Data processing, analysis and data quality control (QC) both at the central and departmental

levels. The DDs have been reinforced in FY 2007 by hiring dedicated M&E staff and have taken on more

responsibilities for data validation and QA/QC. Several mechanisms developed by the USG partners have

been progressively transferred to the DDs. Efforts are now needed to allow the UCC, which only has one

M&E contact person, to backstop the DDs.

Activity 5: Coordination and logistics of M&E training. The MOH will continue to coordinate and support the

logistics of all M&E trainings and workshops. This mechanism has given the MOH leverage to encourage

partners to consolidate training. Instead of having multiple partners holding various training sessions on

different topics, the MOH has been able to create for each target audience (providers, field data staff), one

curriculum integrating contributions from each partners. This consolidation of curriculum which started in

FY 2006 with the organization of workshops for providers and M&E field staff will culminate in FY 2007 with

the implementation of an M&E post graduate course for interns, residents, and other health professionals.

Activity 6: Surveillance and case notification. IN FY 2007 the DELR received technical assistance from

NASTAD to launch an HIV surveillance system with the participation of private laboratories in the

metropolitan area, and initiate the development of an epidemiologic profile for four geographical

departments regrouped under the denomination of "the Great South." These activities will be sustained and

expanded nationwide in FY 2008 for a total of US $300,000. These funds will allow the DELR to (i) scale up

the epidemiologic profile in the 10 departments, (ii) train the DD staff in updating the profile, (iii) expand the

Activity Narrative: HIV case notification system to the provinces by working with private labs throughout the country, and (iiv)

reinforce its own capacity to process, analyze and disseminate data on surveillance.

Activity 7: Development of MESI into a national aggregate reporting system for HMIS. With the

interconnection of MESI and the EMR and its use for case notification of HIV, MESI will soon become the

sole source for HIV data, statistics and surveillance. In FY 2008 the MOH will expand MESI use to

reporting for the entire HMIS. MESI implementers will work with JSI MEASURE for the interconnection with

their HMIS application.The MOH will also provide training on the use of the new HMIS module.

Activity 8: Leadership for the data triangulation process: The MOH will constitute a task force with different

stakeholders to guide the process and assign a point person to chair it. Undre the facilitation of University

of California in San Francisco (UCSF) the task force will help identify key questions based on country

context , convene large stakeholders meeting and disseminate results

•Number of local organizations provided with technical assistance for strategic information activities = 250

•Number of individuals trained in strategic information (includes M&E, surveillance, and/or HMIS) = 500

Integrated Activity: This activity is linked to Activity IDs 3851.08, 5472.08, 3912.08, 3918.08, 5412.08,

3902.08 and 12376.08.

SUMMARY: This component of the program comes in direct support to the Government of Haiti to help: (i)

establish within the Minister Of Health (MOH) a functional system for regulation of the provision of HIV/AIDS

services, coordination of quality assurance and quality control and QA/QC and training activities

nationwide; (ii) strengthen the MOH's financial management and absorptive capacity; (iii) reinforce the

departmental level support to community activities by enabling 10 health departmental directorates to lead

and coordinate all community mobilization activities as well as manage 30 small competitive grants to

community organizations, especially associations of PLWHAs; and (iv) conduct policy and advocacy

activities to develop and finalize norms and protocols, promote the passing of specific laws for protection of

PLWHA and OVC and promote bi-national cooperation between the Haiti and Domincan National AIDS

Programs. This program component should increase the country absorptive and financial management

capacity, contribute to the establishment of a regulatory environment in the provision of HIV/AIDS services,

and reinforce the creation of a grass root national response against HIV-AIDS. The major emphasis areas

for the activity are local organization capacity development and training. The primary targeted populations

are the country coordinating mechanisms, the MOH staff at central and departmental levels, the grass roots

community-based organizations (CBOs), and PLWHAs.

BACKGROUND: Haiti's health care delivery system is divided into three sectors: public facilities,

accounting for about 40% of service delivery; private not-for-profit and mixed public/private partnership

facilities, accounting for another 40%; and private for-profit providers (medical clinics and hospitals),

accounting for 20%. In addition, the MOH fulfills normative, regulatory and supervisory functions through

different directorates established both at the central and the departmental levels.

Years of political instability have led donors to exclusively rely on emergency mechanisms to channel

funding to Haiti. During the first two years of the President's Emergency Plan for HIV/AIDS Relief

(PEPFAR), in the absence of mechanisms to directly fund the publicly-managed activities, support was

channeled through United States Government (USG) private sector partners. While this approach allowed

quick launching of activities, it was accompanied by high overhead costs that reduced funds available for

field activities. With various funding streams linked to different program areas from PEPFAR, the USG

established a cooperative agreement with the MOH, which enabled the Ministry to develop a

comprehensive program involving all levels (central, departmental and publicly managed sites). The

program included: (i) field support for the development of CT, PMTCT, palliative care and ARV services at

25 of the major public hospitals of the country; (ii) the development of lab infrastructures throughout the

country to support the biological monitoring of patients enrolled in services and the reinforcement of a

national laboratory quality assurance/quality control (QA/QC) program; (iii) the reinforcement of a national

monitoring and evaluation (M&E) system to monitor national HIV/AIDS program performance and results

with increased participation of the departmental directorates and; (iv) the creation of small competitive

grants under the leadership of the regional departmental directorates to foster and support local initiatives

from community groups and local public agencies and taking advantage of the decentralized management

at the departmental level. The execution of this program component has resulted in an increased capacity

of the public sector to manage USG funds. In addition, participation of various sectors of the civil society

has been enhanced through the increased channels of support to community activities and the

reinforcement of governance of the program.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Reinforcement of technical, grant and financial management capacity both at the executing unit

of the MOH and at the departmental directorates. The Executing Unit has successfully managed $4,4

million allocated in FY05 and FY06 and has started the execution of a $5.7 million grant in FY07. Money

allocated to the unit has been spent within the limit allowed, in compliance with the USG standard

provisions, and with an overhead cost of less than 20%. In FY08 additional capacity will be needed to allow

both the unit and the 10 departmental directorates to play their technical and fiduciary roles. Focus will be

put on hiring highly skilled professionals, reinforcing the management mechanisms and processes, and

providing training to managers of the sub-recipients in the area of financial management and control. The

estimated cost of the package is US$ 1.5 million, including all overhead cost for the management of the

MOH program.

Activity 2: Competitive grants for grass root- community activities. This activity, which reached four

departments in FY05, and seven in FY07, will be expanded to all 10 in FY08. The grants will finance a

menu of activities proposed exclusively by local community groups or local administrative entities, with

priority to PLWHA organizations. Those activities may include, but are not limited to: awareness and

educational activities, community care or home-based care initiatives, and community day-care centers for

OVC. The regional department directorates will ensure the promotion of this grant facility, interface with

local organizations, facilitate the review of proposals by the regional committees to be put in place,

administer the grants, and oversee the execution of activities by awardees. A total of 30 local organizations

are expected to participate in this initiative. They will receive technical assistance, training and support from

both the Executing Unit and the departmental directorates for management of their awards. Each

department will manage a grant portfolio of $ 40,000 for a total of US $400,000 for the 10 departments.

Activity 3: The setting up of a functional system for accreditation, training, and QA/QC. So far training and

QA/QC are being carried out by multiples entities, including the MOH, which has established with FY06

funding its own capacity to provide training and QA/QC through a consortium of its University hospital,

which has constituted a pool of trainers and mentors with the assistance of I-TECH. Technical assistance

using the methodology HIV/QUAL is planned for this structure in FY07. We propose in FY08 is to organize

this embryonic structure, regroup some senior specialists and broad the national mandate of : (i)

accreditation of centers providing HIV/AIDS services, (ii) train trainers in different areas of HIV/AIDS, (iii)

organize a fellowship for infectious disease specialists, (iv) provide technical assistance and support to the

departmental structures providing training and QA/QC, (v) coordinate all training activities and maintenance

of a training database an, (vi) coordinate the contribution of Haitian health professionals living in the

diaspora, in the context of the national HIV/AIDS curriculum. Trainers and mentors will be organized under

a coordinator working under the supervision of UCC. About US $1,000,000 is needed to improve teaching

capacity at two university hospitals, support the logistics of training, support the logistics of field visits in the

departments and the sites for QA/QC and accreditation purposes, support the logistics of travel and

accommodations for the Haitian mentors from the diaspora.

Activity 4: Support for and participation in the MOH technical committees to revise national norms for ARV

treatment drug regimens and finalize national norms for TB/HIV co-infection management, food and

nutritional support for PLWHA and OVC. Support and participate in efforts to pass the National AIDS Law

and reinforce the legal structures for improved protection of HIV/AIDS-related double orphans, counseling

Activity Narrative: and testing of children and job protection in the National Haitian Police and other national uniformed

services and in the private sector.

Emphasis areas % of effort

Human resources 51-100

Local Organization Capacity Development 10-50

Policy and Guidelines 10-50