To assist MOH with Injection Safety transition as follows:

SUMMARY: The main goal of this project is to reduce the transmission of HIV/AIDS by promoting safe

injections through implementing the three-part strategy recommended by the Safe Injection Global Network

(SIGN): 1) Change behavior of health care workers and patients to ensure safe injection practices and

reduce demand for unnecessary injections, 2) Ensure availability of safe injection equipment and supplies,

3) Manage sharps waste safely and appropriately. In FY08, JSI expanded the program to nationwide

coverage. In FY09, JSI will transition the program to the Ministry of Health.

BACKGROUND: The Safe Injection project started in Haiti in July 2004 with funds from PEPFAR. This

project is commonly known by the abbreviated project name Making Medical Injections Safer (MMIS). The

main goal of this project is to reduce the transmission of HIV/AIDS by promoting safe injections through

implementing the three-part strategy recommended by the Safe Injection Global Network (SIGN). An

assessment of injection safety and waste management issues was conducted in 2004, and the results

reveled that there were no norms and standards for injection safety. Specifically, the problems were

associated with the following identified issues: non-motivated, non-trained staff unaware of the risk

associated with unsafe injections; lack of injection materials in health facilities; lack of infrastructure for

waste collection, treatment and disposal which included no municipal waste disposal, and lack of

supervision of health facilities.

These factors resulted in waste being accumulated on the grounds of the health facilities because of a lack

of knowledge, lack of high performance incinerators, and lack of transportation and a municipal waste

disposal system. Since the initiation of the PEPFAR funding for safe injections, JSI has been working to

address the identified issues through training health care workers regarding safe disposal of shapes waste,

distribution of wall mounted disposal boxes, supporting and strengthened the MOH to develop regulations,

coordinating installation of incinerators throughout Haiti, and implementing a behavior change

communication program targeted at health care workers and clients to reduce the demand for unnecessary

injections.

ACTIVITIES AND EXPECTED RESULTS

JSI will work collaboratively with the MSPP on the following activities until mid FY09. Once JSI's agreement

ends, the transition will be complete to the MSPP who will be responsible for the continuation of the

following activities:

Activity 1: Implement safe and necessary injections as a quality standard in the curative sector. Training will

be conducted with health personnel and support staff in all health facilities at the departmental level. The

training will cover safe injection practices, use of safe injection devices, improved waste logistics

management training as well as interpersonal communication. Training will be conducted on a large scale in

order to achieve nationwide coverage. Thus training will be conducted with, training of trainers, students at

INSHAC and Nursing schools, pre-scribers, frontline health care providers, waste handlers, and supply

managers.

Activity 2: Planning workshops will be conducted at the departmental level in the expansion departments

(Artibonite, centre, Nord-oeust and Ouest) to improve injection safety and waste management in the

facilities. This activity aims at designing and implementing plans for training roll out, supervision, logistics

and supply (mainly syringes and safety boxes), BCC and sharp waste disposal.

Activity 3: Implementation of a behavioral change strategy to reduce unnecessary injections and promote

safe injection practices. BCC materials produced during the FY07 will be disseminated. They were

elaborated with the participation of BCC staff in all 10 departments. They consist of flyers, posters, radio

and TV messages.

Activity 4: Strengthening systems to improve waste management in target areas. MSPP will continue to

promote the need for a national waste management plan, will work with target department for the

elaboration of waste management departmental plan, will help build two waste storage sites, will work with

UNICEF for the installation of the new incinerators and ensure that the staff is properly trained to use them

correctly.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $9,895,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Program Context Area:

As of September 2008, approximately 95,000 people living with HIV/AIDS (PLWHA) have received basic care and support from

the United States Government (USG) team partners. This number represents approximately 50% of the estimated 200,000 HIV

infected persons in Haiti. The USG Team expects to reach about 120,000 PLWHAs by the end of September 2009 and 130,000

by the end of September 2010, with seven percent of this total being children. The program focus is to provide clinical, home

based care as well as psychological, social-economic and community support to PLWHAs enrolled at counseling and testing (CT),

prevention of mother-to-child transmission (PMTCT), anti-retroviral (ARV) treatment and tuberculosis (TB) sites.

For clinical care the priority has been to provide laboratory and clinical assessment and follow up for all PLWHAs detected

through the system to prevent and treat opportunistic infection (OI), to screen for TB, and to ascertain the optimal time for ARV

initiation according to national guidelines. To this end, resources have been provided though the ten care and treatment

networks—Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Partners in Health (PIH),

Ministry of Health (MOH), AIDSRelief and Management Sciences for Health (MSH), International Child Care (ICC), Fondation

Pour La Santé Reproductive et l'Education Familiale (FOSREF), Promoteur de l'Objectif Zéro Sida (POZ), Family Health

International (FHI) and a To Be Determined (TBD) —to reinforce about 100 sites (including about 15 TB sites) throughout the

country with trained clinical and community personnel, basic laboratory testing (including Cluster of Differentiation 4 [CD4]),

patient monitoring tools (chart, register), and regular supplies of laboratory commodities and drugs for OIs. FOSREF and POZ

are two networks specialized in prevention services for youth and men who have sex with men (MSM) respectively in order to

meet specific needs for these high risk groups.

This year the focus will be to reinforce the package of clinical care services with nutritional assessments and distribution of food

and micronutrients as a prescription, and with end of live issues such as pain management according to national norms and

protocols. As the universal distribution of cotrimoxazole has been incorporated in the care and treatment norms, efforts will be

made to fully implement this approach. Linkages are being reinforced between palliative care services, ARV and TB services to

ensure a continuum of care to PLWHAs eligible for highly active antiretroviral therapy (HAART) or diagnosed with TB.

For home based care, the priority has been to build a bridge between the sites and households in order to 1) track HIV patients

(including pregnant women and children) enrolled at these sites; 2) provide minimal care, prevention, and counseling services at

home according to national norms; 3) monitor their adherence to treatment; and 4) make referrals to clinics when necessary.

Over the years, the package of home based care has varied from one network to another. PIH has an important network of

community personnel known as accompaniateurs (companions) that deliver comprehensive directly observed therapies (DOTs),

HAART, social support, and prevention services integrated with TB, sexually transmitted infections (STIs), child survival, and

maternal care. Others like MSH/ Santé pour le Développement et la Stabilité d'Haïti (SDSH) and AIDSRelief have built on existing

community networks for maternal and child health program to deliver HIV home based care integrated with prevention and

education activities. Networks with no other community program, such as GHESKIO, hired specialized health agents to perform

tracking and provide limited HIV care at home.

With existing resources, efforts are being made to standardize and reinforce the package of home based care with minimum

counseling, support, and prevention services that will include distribution of condoms, oral rehydration solutions (ORS) and pain

killers, education directed toward the family for best health and nutrition practices, and for positive attitude based on national

guidelines.

For psychological support, efforts were made to make psychologists available at most ARV sites. These mental health personnel

help reduce denial and improve adherence to treatment by PLWHAs. All of the networks around ARV sites have taken steps to

create PLWHA support groups and are structured to provide emotional support to PLWHAs and their families, promote positive

attitudes and reduce stigma.

Since fiscal year (FY) 07, the USG team has taken steps to address the limited access to socio-economic services, food, and

community preventive care package experienced by PLWHAs to date. In each of Haiti's 10 regional departments, a lead

community-based organization (CBO) has been identified to work through local CBOs and in collaboration with CT, PMTCT, Care

and treatment sites to deliver a package of psycho-social, community and economic support as well as preventive care services to

PLWHAs and their families. The program has integrated this package with orphan and vulnerable children (OVC) services to offer

a family-centered approach. Emphasis was put on: distribution of food through linkages with Title II food programs, commodities

for safe drinking water, hygiene kits, bed nets for malaria prevention in linkages with the Global Fund for AIDS, Tuberculosis and

Malaria (GFATM) and the MOH partners, psychological and counseling support services through PLWHA support groups, etc.

This approach has been successfully implemented this year and a continuum of support has been provided to most of the patients

enrolled in clinical care and treatment services from the clinics to the community. In addition the USG has identified a fortified,

precooked food product for distribution to PLWHAs, by prescription, at the clinic. A plan of distribution has been put in place to

make this food available through different sites for malnourished PLWHAs including children.

With FY 2009 resources the USG will continue to support the same package of clinical, psychological, home based and socio-

economic services as is being reinforced this year to reach close to 130,000 patients by September 2010. The point of entry for

these patients will continue to be the system of care. The number of sites offering clinical care will be expanded to 120, including

20 TB sites. Emphasis will continue to be put universal distribution of cotrimoxazole. Thru the CBO, efforts will be made to scale

up the package of socio-economic and community support in all ten departments to provide services to 100% of PLWHAs thru the

family centered approach with particular emphasis on: a) providing shelter to PLWHAs in need; b) nutrition assessment,

counseling and feeding support for clinically malnourished PLWHAs as a component of clinical care and treatment (Food by

Prescription); c) link with the OVC program for school fees support; d) leveraging with other non-governmental organizations

(NGOs) involved in job creation and receiving United States Agency for International Development (USAID) funds such as Konbit

ak Tèt Ansanm (KATA) and the Cooperative Housing Foundation (CHF), to provide jobs and income generating activities to a

greater number of PLWHAs; e) linkages with churches to provide more spiritual care to PLWHAs and their families.

More emphasis will be put this year on addressing the needs of infected and vulnerable children. With the increased food

insecurity in Haiti, the rate of child malnutrition is expected to worsen. Food by prescription at the sites will address both the issue

of malnourished children with the ready to use therapeutic feeding (RUTF) as well as preventive intervention for micronutrients

deficiency with fortified blended food for children from 6 months to 3 years, pregnant women and lactating women. Safe water

use for the family will be promoted as an element of the package to decrease the episodes of diarrhea which is a leading cause of

infant mortality in Haiti. Comprehensive clinical approach with improved coverage for immunization, regular weight control,

Vitamin A supplementation and de worming will add on the complete the services provided to the children in terms of care and

support.

The main partners for this program will be the ten networks mentioned above (MOH, PIH, GHESKIO, AIDS Relief, FOSREF, POZ,

MSH, ICC, FHI and TBD) that will continue to provide clinical care in linkages with treatment services. For community support

services, FHI will continue to be the main CBO for two departments (North and South East) while for the other 8 departments new

mechanisms are being determined thru a competitive process this year to channel this support. The program will procure

laboratory supplies and equipment as well as OI drugs and preventive care commodities through the Partnership for Supply Chain

Management (PFSCM). POZ will continue supporting PLWHA support groups and PLWHA associations.

Program Area Target:

Number of service outlets providing HIV-related palliative care (excluding TB/HIV): 130

Number of individuals provided with HIV-related palliative care (excluding TB/HIV): 130,000 (9000 being children)

Number of individuals trained in clinical care: 300

Number of individuals trained in community palliative care: 800+

Table 3.3.08: