The narrative will be modified in the following ways:

Activity 01: Conduct the 6th annual sero surveillance survey. This activity will repeat the annual sero

surveillance survey to estimate the current trends of the HIV and syphilis epidemics among 10,000 pregnant

women attending 25 PMTCT sites and will estimate for the first time, the incidence of HIV among that

population. The survey will take into account the experience gained in COP 08 in implementing the sero

survey in the PMTCT network, and will use again the methodological approach used to estimate the

prevalence of HIV and syphilis. In addition, the technology of AwareTM BEDTM EIA HIV-1 test will be used

to estimate the HIV incidence. The planning and implementation phases of the survey will be accomplished

by IHE in close collaboration with the MOH National Lab and the CDC local Lab Advisor. At the end of

March 2010, a report will be published that presents trend analyses of the HIV and syphilis epidemics

among pregnant women and an estimate of the incidence of HIV infection.

Activity 02: Monitoring of Early Warning Indicators (EWI). IHE will continue monitoring the Early Warning

Indicators (EWI) of Anti-retroviral Resistance based on the guidelines adopted by the World Health

Organization and using the Electronic Medical Records (EMR) that are in use at the different ART sites -

records that were developed by the International Training and Education Center on HIV/AIDS (I-TECH),

Partners in Health (PIH) and "Groupe Haïtien d'Etudes du Sarcome de Kaposi et des Infections

Opportunistes" (GHESKIO). The objective of this activity is to assess the extent to which the ART program

is working to optimize the prevention of HIV drug resistance. Approximately 45 institutions in the ART

network that have patients registered for at least six months of ART will be targeted; the primary period

under study will examine patients enrolled from January through June 2008 and followed for one year. In

addition, IHE will examine at 24 months of ART, the cohort enrolled from January through June 2007. IHE

will use the same methodological approach used during the preceding year, with emphasis on data

validation and extensive auditing of data collected that compares data from the EMR with data collected

using the manual tools/records in use at the different sites. IHE will work with I-TECH, PIH and GHESKIO to

update the EMR software to allow the electronic extraction of data. IHE will also work in close collaboration

with the Ministry of Health and the Pan American Health Organization (PAHO) in Haiti to implement this

activity and analyze the data. At the end of December 2009, a report will be issued that indicates the level of

the EWI for Anti-retroviral Resistance at the different sites and that provides appropriate recommendations.

Activity 03: Evaluation of HIV primary drug resistance. The objective of this activity is to evaluate the extent

of transmitted HIV drug resistance at selected sites. The protocol developed by WHO and CDC and used in

COP 08 by IHE in a pilot phase will be revised based on the experience gained in the previous year. This

evaluation will be carried out at three selected sites within the ANC/PMTCT sero sentinel network

representing respectively the Metropolitan area, the urban area and the rural area. The target population will

be pregnant women attending the ANC/PMTCT sites who are under 25 years of age, in their first

pregnancy, and not previously on ART. The evaluation of the extent of transmitted HIV drug resistance will

be performed using genotyping characterization, determined by a specialized lab recommended by the

World Health Organization (WHO) and CDC. IHE will work closely with the local CDC and Pan-American

Health Organization (PAHO/WHO) offices in implementing this evaluation. By the end of March 2010, a

report will be presented indicating the level of HIV resistance by site for each drug and each class of drugs

as <5%, 5-15% and >15%.

Activity 04: Develop and implement a monitoring system for children born of HIV positive mothers. With

support from UNICEF, IHE conducted a primarily qualitative study of existing services for children born of

HIV-infected mothers. The results of that study indicate that a successful intervention for these children

needs to begin during the pregnancy of the HIV+ woman. The follow-up of children born of HIV+ mothers

begins at birth, which requires an effective coordination of services inside the hospital starting with a

coordination of maternity and pediatric/ infant-care services. The study also identified a need to have a

community-based component to encourage that post-partum and post-natal medical visits happen as

scheduled and to determine and overcome the difficulties each mother confronts in assuring appropriate

care of their infants/children.

The objective of this activity is to ensure the proper follow-up and care of children born of HIV positive

women that takes into account the extremely limited number of those children who previously benefited

from proper care.

Under this activity, IHE will establish a comprehensive monitoring system that tracks services for HIV+

pregnant women and their infant children, beginning with the proportion of seropositive women who deliver

in hospitals and the proportion of children born of HIV+ mothers who are enrolled in the PTMTC program.

IHE will also track the mechanisms in place to encourage hospital-based deliveries and the operation of

community-based systems of support and training available for HIV+ mothers. This activity will primarily

focus on monitoring the services provided to these children, the evaluation of the clinical and biological

status of the children - using the evaluation system developed jointly by PAHO/WHO and UNICEF-, the

treatment received by those children and their survival status at 3, 12 and 24 months.

This activity will be implemented in 15 institutions delivering PMTCT+ services with a Community Palliative

Care (Care and Support Program) component.

IHE will orient the staff at collaborating institutions in the use of the monitoring system to improve the quality

and comprehensiveness of health and support services provided to children born of HIV positive mothers.

IHE will work closely with the MOH, the CDC, the United States for International Development (USAID) and

the United Nations Children's Funds (UNICEF) offices in implementing this activity. After finalizing the list of

indicators with these partner institutions, IHE will devise and establish an appropriate monitoring system

based on existing data collection mechanisms and avoiding duplications and inefficiencies.

A report will be submitted by March 2010 that presents practical recommendations aimed at generalizing a

system of child follow-up and care that is associated with and intergrated into existing health information

systems.

Activity Narrative: BACKGROUND

This project, funded by PEPFAR through a cooperative agreement between the Centers for Disease Control

and Prevention (CDC) and IHE since September 2004, is ongoing. It will build upon accomplishments of

preceding years, taking into consideration progress made and lessons learned in tracking reports, validating

data, providing technical assistance to individual sites, supporting development of the Monitoring and

Evaluation Surveillance Interface (MESI) electronic system and supporting training sessions on the

HIV/AIDS information system.

This project is supported by the Haitian government. All activities will be implemented directly by IHE, but

particular attention will be paid to work more closely with MOH staff, reinforcing the existing working

relationship. However, there will be no major change in the strategic approach. We will focus on data

analysis and utilization of information.

ACTIVITIES AND EXPECTED RESULTS

Activity 1 - See above

Activity 2 - See above

Activity 3 - See above

Activity 4 - See above

Activity 5 - Support to the development of MESI: IHE will continue to provide inputs for the development

and upgrade of MESI. IHE will ensure implementation of these specific activities: identification and

development by SOLUTIONS of new reports related to monitoring of site activities and site performance in

order to respond to the needs of strategic information, introduction in MESI of new tools that facilitate data

analysis and quality control, and train site and departmental personnel to be able to use MESI and ensure

sustainability. A revised version of MESI's web application with the new functionalities will be available by

December 2008 in all sites and used by 100% of the site personnel.

Activity 6 - Conduct a sixth round of the ANC sero survey in the existing network of sites. The

methodological approach used will be the same as in the preceding years with a complementary component

to compare classical ANC sero survey with usual PTME (spell out) monitoring system, in order to test the

possibility to use the regular PMTCT monitoring system as an instrument for trend analysis of HIV epidemic

among pregnant women. In-depth participation of the MOH staff will be sought at central and peripheral

levels to assure progressive transfer of this activity to MOH. At the end of December 2008, a report will be

available on trend analysis of HIV epidemic among pregnant women.

Activity 7: Collect data on Early Warning Indicators of Anti-retroviral Resistance per guidelines of the World

Health Organization. IHE, with the support of the Pan American Health Organization (PAHO) in Haiti,

began collection of non-laboratory data for Early Warning of Anti-Retroviral Resistance using the Early

Warning System of the WHO. Genotyping characterization, the laboratory component of this surveillance

system, will be performed this year using funding from PAHO. For 2008, however, continued collection of

data (including individuals lost to follow-up, no shows for appointments, etc) will be collected from ARV sites

during visits for the routine validation of data.

Activity 8: Support UCSF for the Triangulation. IHE (the local partner) will subcontract University of

California at San Francisco (UCSF) in the planning and implementation of the triangulation. They will

collaborate in the definition of questions, the gathering of data/reports, facilitation of meetings, analysis of

data and drafting of reports. They will recruit a high level local consultant specialized in modeling and

handling of data to lead that effort.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17184

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17184 3907.08 HHS/Centers for Institut Haitien de 7683 3144.08 $600,000

Disease Control & l'Enfant (Haitian

Prevention Child Health

Institute)

9284 3907.07 HHS/Centers for Institut Haitien de 5125 3144.07 $1,300,000

Disease Control & l'Enfant (Haitian

Prevention Child Health

Institute)

3907 3907.06 HHS/Centers for Institut Haitien de 3144 3144.06 $265,000

Disease Control & l'Enfant (Haitian

Prevention Child Health

Institute)

Table 3.3.17: