SUMMARY: With Fiscal Year (FY) 2009 resources, ICC will strengthen basic care and support in its

network of 20 TB clinics that have been reinforced this year to provide HIV services. This program will be

linked with the TB/HIV, ARV, CT, and PMTCT services as well as community based programs that are

being offered in the vicinity of these clinics. The target populations include people living with HIV/AIDS and

their families.

BACKGROUND: ICC has been a key player in the system of care in Haiti. They are well known for their

important role in supporting the TB program in Haiti throughout the country. Through Grace Children's

Hospital, an affiliated non-governmental organization (NGO) hospital, ICC has been providing specialized

TB care, integrated with primary and general care for both adult and children, with support from USAID and

the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Since the launch of the President's

Emergency Plan for AIDS Relief (PEPFAR), the United States Government (USG) has been providing

resources to ICC to integrate HIV in its network of TB sites. So far about 10 TB clinics have been reinforced

to provide CT and HIV basic care. With FY 2008 resources, this program will be expanded to 20 TB clinics.

In FY 2099, the USG will continue to provide resources through ICC to reinforce basic care in the 20 clinics

targeted last year. The focus will be to provide clinical, psychological, nutrition, and laboratory assessment

and follow up to 3000 patients to prevent and treat opportunistic infection (OI) and malnutrition, and to

monitor the optimal time for providing highly active antiretroviral therapy (HAART). ICC will establish strong

links with ARV services to ensure continuum of care for those in need of HAART and TB care.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Through the network of 20 TB sites, all patients testing positive will be enrolled in clinical palliative

care. Thereafter, they will receive access to laboratory, clinical, nutrition, and psycho-social assessments,

and follow up services to prevent and treat opportunistic infections, malnutrition, and pain and symptom

management. Additionally, ICC will monitor the optimal time for providing HAART and will refer patients in

need of treatment to ARV sites. Funding will be used to staff each palliative care site with a multi-

disciplinary health care team, including physicians, nurses, psychologists, social workers, counselors,

nutritionists, community health workers, and laboratory technicians. Emphasis will be put on training health

nurses to play a key role in providing these services (see MSPP palliative care narrative). Funding will

support enhancements of infrastructure, equipment, materials, and supplies for service organizations at

clinics, laboratories, and pharmacies. ICC will conduct these activities in conjunction with Supply Chain

Management System which will provide laboratory reagents and commodities and opportunistic infection

drugs.

Activity 2: Human capacity building:

ICC will ensure that clinical and community staff around the sites receive continuous training, supervision,

and QA/QI assistance to acquire and maintain necessary skills in HIV/AIDS care and treatment. Emphasis

will be put this year on training health professionals in nutrition assessment, follow up, and recuperation to

make sure that all sites are integrated with nutrition services. ICC will work with GHESKIO, INSHAC, and

MOH to achieve these goals (see aforementioned organization's narratives).

Activity 3: Social support services:

Special attention will be given to the need for social support for patients enrolled in the palliative care

program. Funding will allow to hire social worker at the sites that will be in charge of assessing the social

needs of all PLWHAs and provide them social support services. Sites will provide direct support (e.g. fees

for services such as delivery, hospitalization, x-ray) and for transportation to appointments. Patients will also

be referred to the PLWHA association and community based organizations (CBO) in charge to offer

community palliative care services.

Activity 4: Home based care

ICC will increase the number of community health workers at the sites to accommodate scale-up of

palliative care services. 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,

provide health education on best health and nutrition practices, counseling for positive behavior, distribution

of care and preventive commodities such as condoms, ORS, symptom and pain medications according to

the guidelines. Community workers will be trained in symptom recognition, and syndromic treatment and

rapid assessment of psychosocial problem of patient.

Activity 5: Psychological support

Funding will also be used to continue to support PLWHA support groups around each site to create a

supportive environment for treatment adherence and stigma reduction. In addition, local community leaders,

traditional healers, and religious leaders will be incorporated to encourage and enhance support of patients

within the community. ICC will work with other CBOs to continue to penetrate the religious sector in an effort

to bring HIV/AIDS and treatment awareness to the forefront in churches and religious groups and to get

them involved in providing spiritual care to patients.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18985

Continued Associated Activity Information

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

System ID System ID

18985 18985.08 HHS/Centers for International Child 7684 3684.08 $400,000

Disease Control & Care

Prevention

Table 3.3.08:

SUMMARY: With additional resources, International Child Care (ICC) will continue to support the national

effort to strengthen and expand the Tuberculosis (TB)/ HIV program throughout the country. Building on the

successful implementation of the TB/Directly Observed Treatment Short-Course (DOTS) program and a

large network of HIV care and treatment services, ICC will focus on strengthening and expanding HIV

counseling and testing (CT) services as well as care and treatment services within its network of TB clinics

with no HIV services. ICC will focus on those clinics with high volumes of TB patients to ensure that all TB

patients enrolled in these clinics get access to HIV screening and care as needed. ICC will ensure that in

the other TB clinics, all TB patients get access to HIV screening and HIV care as needed thru linkages with

HIV sites. ICC will also provide technical assistance to the sites with both HIV and TB services to ensure

full integration of these services. ICC will support implementation of a TB/HIV center of excellence at Grace

Children's Hospital for training and quality assurance/quality improvement (QA/QI). ICC will provide

technical support ICC will provide technical support to the MOH to develop national norms, guidelines, and

tools to build human capacity, improve monitoring (including drug resistance) for the TB/HIV program and to

implement TB infection control measures.

BACKGROUND:

Over the last 30 years ICC has been a key partner of the Ministry of Health (MOH) in the fight against TB in

Haiti. Since 1995, ICC has played an important role in rolling out the TB/DOTS strategy adopted by the

MOH, and providing support to implement TB/DOTS services in five departments (North, South, South East,

West, and Central Plateau), and the overall management of the program in planning, training, monitoring,

supervision, and logistics. ICC is operating through an important network of hospitals, health centers, and

few stand alone TB clinics. One of them, Grace Children's Hospital located in the Port-au-Prince-

metropolitan area, specializes in providing TB care, particularly to children and provides such care to a large

number of patients in integration with other primary health care services. This hospital has the potential to

serve as a center of excellence for training and QA/QI.

Since 2005, the United States Government (USG) elected to build on ICC expertise and its network of TB

clinics to implement TB/HIV services. TB clinics located in the five other departments where ICC does not

have a presence have been supported through the two other lead TB non-governmental organizations

(NGOs), Cooperative for American Relief Everywhere (CARE) and the Centre Pour Le Développement et la

Santé (CDS). The main focus of ICC has been to integrate CT services as well as HIV basic care in the TB

clinics with no HIV services and to establish referrals with antiretroviral (ARV) services for co-infected

patients in need of highly active antiretroviral treatment (HAART). In TB clinics where HIV services have not

been integrated, ICC has made the effort to link them with HIIV sites in the same area to provide HIV

services to TB patients. This activity has been linked with other USG efforts to integrate, through care and

treatment HIV networks, CT services in TB wards located in facilities offering both HIV and TB services.

To date, through the ICC network, ten TB sites have been reinforced to provide HIV counseling, testing, and

basic care services. With Fiscal Year (FY) 2008 resources, the USG expects to expand this effort to 15 sites

(including 5 new). As the USG has stopped to provide HIV/TB resources to CARE, ICC has expanded its

support to five other departments: Grand' Anse, Nippes, Artibonite and North East. The other 10th

department (North East) will continue to receive TB/HIV support thru a TBD partner. In addition, ICC,

together with the other lead TB NGOs, has played an important role in developing tools for TB/HIV

monitoring. ICC has also developed the capacity, through a mobile team, to perform supervision and QA/QI

for TB/HIV.

With FY 2009 resources, the USG will continue to build on the ICC TB network to expand and reinforce

TB/HIV services in nine departments. Through ICC the 15 TB sites targeted this to be integrated with CT

and HIV care services will be strengthened. In addition, ICC will continue to build a strong referrals system

in each department between the other TB sites that do not have HIV services with HIV sites located in their

target areas. In addition, ICC will continue to play a major role in policy development, human capacity

building by providing hands on training, supervision and QA/QI for the program through their mobile team

that will be reinforced with trained health professionals in TB/HIV care. ICC will also assist Grace Children's

Hospital to become a TB/HIV center of excellence (COE) that will have the logistic and human resources

capacity to train health professionals in TB/HIV for the care and treatment networks. This effort will add to

the effort initiated at Sigueneau Hospital thru GHESKIO to make it also a center of excellence for training.

EXPECTED RESULTS: Through ICC, 10,000 TB patients (representing 66% of expected TB patients

throughout the nation) will obtain access to HIV screening services. We expect that 20% (2000) will be HIV

positive and will enroll in care while 5% (500) will enroll in ARV.

Activity 1: ICC will allocate resources to support service organizations at 15 TB clinics (including six new)

with the highest volume of TB patients throughout 9 department service area. ICC will use these resources

to hire at each site the range of human resources personnel (counselors, physicians, community and social

workers), reinforce infrastructure (including laboratory) to deliver counseling services and HIV palliative

care, including clinical and community follow up. ICC will also reinforce in coordination with the national lab

and Supply Chain Management System (SCMS) laboratory capacity at each site so that laboratory

personnel are able to perform CD4 testing to detect co-infected patients in need of ARV. These 20 TB sites

will be part of the palliative care network sites that will benefit support for opportunistic infections (OIs)

through SCMS -- (see SCMS narrative) and support social services through the community-based

organizations (CBOs) that are offering these services in the different departments.

Activity 2: ICC will establish linkages between the 15 targeted TB sites and the ARV sites in their catchment

area to ensure continuum of care for co-infected patients in need of HAART. ICC will also establish

referrals between other TB clinics where HIV services are not integrated and existing CT sites to allow

access to HIV screening for TB patients detected at these sites. ICC will allocate resources to cover

transportation cost\s as well as accompaniment for these patients to the CT sites.

Activity 3: ICC will continue to support a mobile team to monitor and supervise the TB/HIV program.

Resources will be used to hire and train a team of specialized counselors, physicians, data managers, and

Activity Narrative: social workers in TB/HIV and to support their travel to different sites.

Activity 4: ICC will participate in all national efforts to further develop and review the norms, protocols,

guidelines, and training tools for TB/HIV with emphasis on those related to TB infection control and drug

resistance, TB/HIV pediatric care, and program monitoring. Resources will be used for the dissemination of

these documents through the ICC network. ICC will be responsible for implementing and monitoring

infection control measures in its sites according to national norms and guidelines. ICC will also participate

in the national plan of monitoring of TB drug resistance by allocating resources to the sites for tracking of

suspected TB drug resistance cases, collect of sputum specimens from these cases and processing of

these specimens to the National Lab for culture and resistance testing.

Activity 5: ICC will focus on reinforcing Grace Children's Hospital so that it can become a COE. This will

complement GHESKIO's (another COE) efforts to establish Sigueneau Hospital as a COE as well.

Resources will be allocated to Grace Children's Hospital to hire a specialized team of nurses, physicians,

social workers, and data managers that GHESKIO will train as trainers. This team will be responsible for

training providers at Grace Children on TB/HIV in addition to the training undertaken thru GHESKIO.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17185

Continued Associated Activity Information

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

System ID System ID

17185 5301.08 HHS/Centers for International Child 7684 3684.08 $1,000,000

Disease Control & Care

Prevention

9286 5301.07 HHS/Centers for International Child 5127 3684.07 $910,000

Disease Control & Care

Prevention

5301 5301.06 HHS/Centers for International Child 3684 3684.06 $75,000

Disease Control & Care

Prevention

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

The narrative will be modified in the following ways:

To reinforce the opt-out strategy, lab technicians will be placed in each service to make the rapid test and

therefore diminish the waiting time and increase the testing rate for HIV.

Activity 2: ICC will work with GCH to promote community mobilization, such that GCH is recognized as the

area leader in issues related to HIV testing and care. "Health Field Agents" will be hired and trained to go to

the patient's living quarter for follow-up and ensuring the patient's observance to the treatment. This will

also increase ICC's retention patient ratio. Emphasis will be placed on messages addressing gender

equity, stigma, and discrimination. Juvenile specific educational materials aiming at HIV positive children

will be created and distributed so the parents and the children can efficiently learn and deal with the disease

in a positive way. The goal is to assist them to grasp and cope with the health related issues and the

children to be less traumatized growing up. Furthermore, educational materials (i.e. pamphlets, brochures,

newsletters, etc…) will be made available to all the patients visiting the hospital. The materials will be used

as a tool to teach and familiarize the patient (including friends, families, and neighbors) with the disease

while promoting healthy habits.

Activity 3: All patients who may be TB positive (particularly patient with symptomatic respiratory problem)

will be provided a face mask to prevent the spread of the germ while in the hospital.

Grace Children's Hospital has been receiving assistance from PEPFAR under the umbrella of Management

Sciences for Health, thus this is not a new activity, but the growth of a sub-partner to full partner status as

ICC has been receiving funds in previous years for TB activities requires ICC to create this proposal.

SUMMARY:

International Child Care (ICC) is an NGO that runs Grace Children's Hospital (GCH) in Port-au-Prince and

provides support to 137 stand-alone TB clinics. Grace Children's Hospital has been receiving support from

PEPFAR in previous years as part of the MSH umbrella. In 2009, however, due to the demonstrated quality

work, ICC will be receiving funding directly from USG for GCH and 7 of the 137 TB clinics in Haiti. This

funding will reinforce the counseling and testing program that is offered to every patient at GCH and TB

clinics. Quality counseling and testing services, including palliative care and ARVs will be provided. To

successfully achieve this goal, the focus will be on strengthening, creating or modifying the following:

community mobilization/participation, information, education and communication. The project will improve

the level of care and services that are provided to those living in the Delmas municipality. GCH

implemented the 100% provider strategy - initiated (i.e. all providers offer testing to all patients) on January

to March 2007 and increased the number of tested person from an average of 500 at the beginning of the

program to 2,173 in May 2007. During the same period, the number of HIV positive patients increased from

70 to 140. This same strategy will be initiated in 2009 at 16 of the 137 TB clinics supported by ICC.

BACKGROUND:

GCH began a voluntary counseling and testing (VCT) program in August 2003, although counseling and

testing services were available for pregnant women, TB patients, and other patients with sexually

transmitted diseases toward the end of 1990. GCH is one of the most frequented health facilities in the

country. It receives references for multiple HIV related servicer issues including VCT, Palliative Care and

anti-retroviral (ARV) services from a number of different health centers. GCH coordinates their

interventions and programs with a wide range of other organizations including other PEPFAR partners.

With all health care providers offering HIV testing to all patients, GCH greatly increased the number of

diagnosed HIV positive patients.

ACTIVITY I

ICC will expand Counseling and Testing services at GCH, and make counseling and testing services readily

available to all people visiting the hospital. In order to provide adequate space for this activity, GCH will

need to renovate three additional rooms to accommodate HIV patients using the hospital.

ACTIVITY II

ICC will work with GCH to promote community mobilization, such that GCH is recognized as the area leader

in issues related to HIV testing and care. Emphasis will be placed on messages addressing gender equity,

stigma, and discrimination.

To facilitate service utilization, GCH will provide quick and easy access to transportation, and provide

support to patients living in slum areas.

ACTIVITY III

ICC will emphasize tuberculosis, HIV/AIDS and TB/HIV problems through meetings at GCH as well as 7 TB

clinics using community groups, schools, churches, and mass media. They will produce informational

materials focusing on making behavioral changes. These sites will produce didactic material and use

audiovisual equipment in waiting rooms to facilitate the transmission of information. Lastly, GCH will

renovate its waiting room to better accommodate its clients with better ventilation and lighting.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18957

Continued Associated Activity Information

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

System ID System ID

18957 18957.08 HHS/Centers for International Child 7684 3684.08 $100,000

Disease Control & Care

Prevention

Table 3.3.14: