NOTE: The activities described below are not new, but have been performed by the Centres Pour le

Developpement et la Sante (CDS) under the umbrella of Management Sciences for Health. Steps have

been taken to put into place a mechanism for a follow-on TBD partner to continue these activities.

SUMMARY: TBD will establish a network of seven centers (Centre La Fossette, Hôpital de Fort Liberté,

Hôpital de Ouanaminthe, Centre de Mont Organisé, Centre de Trou du Nord, Centre de Terrier Rouge,

Centre de Mombin Crochu at the North, North-East health Departments and one in the metropolitan area of

Port-au-Prince : the Centre de Petite Place Cazeau. The same model used by GHESKIO will be

implemented for the provision of a full package of PMTCT services to both mother and infant. The primary

targets of this intervention are the 10,000 pregnant women, which on average attend services at these

facilities.

BACKGROUND: For more than 15 years, CDS has established a strong partnership with the Ministry of

Health managing its public sites and providing a comprehensive package of child survival, Reproductive

Health, Tb services. CDS has reached enough expertise to develop its own network for the provision of

HIV/AIDS prevention, care and treatment services that include PMTCT. Such as GHESKIO and PIH, the

four pillar model will be implemented . At community level, health agents who provide services will be

seconded by those of the Palliative Care program: World Concern/AERDO for the metropolitan area, Family

Health International in the North and PLAN in the North-West department.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1. Field support to 8 VCT/PMTCT sites that will enable them to provide a full package of services

including: (i) Opt-out Counseling and testing to all pregnant women (ii) STI management using a syndromic

approach iii) Prophylaxis of opportunistic infections (OIs) (iv) Reproductive health services, including safe

obstetric practices and family planning counseling for HIV positive individuals and the promotion of

condoms; (v) Psychosocial support through individual and family counseling, mainly by social workers and

community health workers and through the setting up of support groups (vi) Case management of HIV

positive pregnant women including clinical and biological monitoring (vii) short-course ARV regimen for HIV-

positive women according to national guidelines (viii) education on best infant feeding practices.

Activity 2. The funding will support: (i) hiring of more qualified staff, (ii) hiring of dedicated social workers

and community health agents for PMTCT, (iii) acquisition of educational materials and support equipment to

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

Activity 3: The creation of a retention package, which includes: (i) subsidies for the cost of follow-up visits

and hospital delivery (ii) maintenance of women support groups (iii)incentives to TBAs

Activity 4: Implementation of an integrated PMTCT (+) package model. This activity implies the

implementation of an integrated family-centered PMTCT (+) approach that will offer HIV/AIDS partner

referral services, couple counseling and reference to Justitnien Hospital (North main departmental hospital)

for the provision of pediatric care to infants born from HIV+ women.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17928

Continued Associated Activity Information

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

System ID System ID

17928 17928.08 HHS/Centers for To Be Determined 7716 7716.08 HIV/AIDS

Disease Control & Clinical Services

Prevention

Table 3.3.01:

SUMMARY:

With Fiscal Year (FY) 2009 resources, the TBD will support the national effort to strengthen and expand

care and support program in the North East (NE) Department of Haiti, in one North Department health

center (La Fossette), and in one health center in the West Department. This TBD contractor will focus on

integrating palliative care basic care in its network to ensure that all HIV positives identified thorough its

counseling and testing (CT) program receive access to clinical, biological, nutritional, and psycho-social

assessment and services as well as long term follow up to determine the optimal time for highly active

antiretroviral therapy (HAART). TBD will integrate this program with anti-retroviral (ARV) and tuberculosis

(TB)/HIV services that are offered in its network.

This project is part of a larger initiative begun in 1989 through a partnership between Centres pour le

Développement et la Santé (CDS) and the Ministry of Health (MOH) according to which CDS directly

managed the MOH's health infrastructures and personnel in a network of health centers located in the NE,

North, and West Departments. In 1994, CDS signed a subcontract with MOH to implement and supervise

TB/ Directly Observed Treatment Short-Course (DOTS) activities in the entire North East Department. The

United States Government (USG) has built on CDS experience in primary health care and TB, to launch

integrated HIV services, including CT, care and support, ARV as well TB/HIV. With existing resources, two

facilities (Ouanaminthe and Fort Liberté hospitals) in the NE Department have been reinforced with

integrated CT, palliative care, and ARV services. Nine hundred forty two (942) HIV positive patients have

been enrolled in palliative care.

Efforts will be made to expand CT services through 10 points of service within CDS's network with FY 2009

resources. TBD will ensure that at least five of them offer in addition a package of palliative care services.

TBD will be expected to enroll 2,500 patients in palliative care basic care by the end of September 2010.

Referrals will be strengthened between the ARV and TB points of services offered either by CDS (in the NE

Department) or other networks (in the North and the West) to ensure a continuum of care for those eligible

for HAART and or diagnosed with TB.

Since the North East Department shares its border with the Dominican Republic (DR), TBD will continue to

make efforts to address cross border issues to ensure that migrant people living with HIV/AIDS (PLWHAs)

enrolled in programs receive access to continuous care on both sides of the island. TBD will build on

successes made so far on bi-national efforts to put in place a unified information system for TB and on the

progress made at the border in the Central Plateau between Partners in Health (PIH) and Elias Pinas'

health officials to have a joint and integrated program of HIV and maternal care.

ACTIVITIES AND EXPECTED RESULTS

Activity 1:

Service Organization: TBD will ensure that all patients tested positive at any point within its service network

will be enrolled in clinical palliative care through the five palliative care sites. Thereafter, they will receive

access to laboratory, clinical, nutrition, and psycho-social assessments and follow up services to prevent

and treat opportunistic infections (OIs), malnutrition, and pain and symptom management. Additional

services include monitoring optimal time for HAART and to create a supportive environment for adherence

to long term follow up and care. 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 (CHWs), 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).

TBD will also use resources to support enhancements of infrastructure, equipment, materials, and supplies

for service organizations at clinics, laboratories, and pharmacies. TBD will conduct these activities in

conjunction with the Partnership for Supply Chain Management (PFSCM) which is responsible for providing

laboratory reagents and commodities and OI drugs.

Activity 2:

Human capacity building: TBD will ensure that clinical and community staff receives continuous training,

supervision and quality assurance/quality improvement (QA/QI) to acquire and maintain necessary skills in

the care and treatment of people infected with HIV/AIDS. Emphasis will be put this year on training health

professionals in nutrition assessment, follow up, and recuperation to make sure that all the sites are

integrated with nutrition services. TBD will work with Haitian Group for the Study of Kaposi's sarcoma and

Opportunistic Infections (GHESKIO), Haitian Institute for Community Health (INSHAC) and MOH to achieve

these goals (see aforementioned organization's narratives). To sustain a workforce of the highest quality,

TBD will continue to reinforce its technical team of care and treatment and monitoring and evaluation (M&E)

specialists to provide on-going training and technical support on a regular basis.

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 enable TBD to hire at each site a social work team lead by a social

worker that will be in charge of assessing the social needs of all PLWHAs and provide them social support

services. Direct support such as fees for services (delivery, hospitalization, x-ray, etc) and for transportation

to appointments will be provided through the sites. Patients will also be referred to the PLWHA association

and community based organizations (CBOs) in charge to offer community palliative care services (see

AERDO, CRS, TBD, and Plan activity narratives for palliative care). A social worker will be added to the

TBD team to provide program oversight.

Activity 4:

Home based care: TBD will increase the number of CHWs to accommodate scale-up at each of its

palliative care sites. The CHWs 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, oral rehydration system (ORS), symptom and pain medications etc.

according to the guidelines. CHWs will be trained in symptom recognition, and syndromic treatment and

rapid assessment of psychosocial problem of patient.

Activity Narrative: Activity 5: Psychological support:

Funding will be used to make psychologists available through the TBD network to provide support to

PLWHAs to reduce denial, assist in psychological assessment and follow up, and to prepare for HAART if

needed. TBD will 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. TBD 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: 18952

Continued Associated Activity Information

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

System ID System ID

18952 18952.08 HHS/Centers for To Be Determined 7716 7716.08 HIV/AIDS

Disease Control & Clinical Services

Prevention

Table 3.3.08:

New/Continuing Activity: Continuing Activity

Continuing Activity: 18975

Continued Associated Activity Information

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

System ID System ID

18975 18975.08 HHS/Centers for To Be Determined 7716 7716.08 HIV/AIDS

Disease Control & Clinical Services

Prevention

Table 3.3.09:

SUMMARY: Building on the successful implementation of the tuberculosis (TB) / Directly Observed

Treatment Short-Course (DOTS) program and a network of HIV care and treatment services, the TBD

partner will support the national effort to strengthen and expand the TB HIV program thru the Centre pour le

Développement et la Santé (CDS) network in the entire North East Department of Haiti, in the North (one

institution) and in the West department (three institutions). The primary emphasis of TBD will be to integrate

HIV counseling and testing (CT) as well as care and treatment services within the TB clinics with no HIV

services in the North East department to ensure that all TB patients enrolled in these clinics get access to

HIV screening and care as needed. The TBD will also support the integration of TB screening, prophylaxis,

and treatment in the network of CT, HIV basic care and treatment sites supported thru CDS located in the

North East, the North and the West departments. TBD will participate along with the Ministry of Health

(MOH) and other lead TB non-governmental organizations (NGOs) in the development and/or improvement

of national norms, development of guidelines and tools to build human capacity, improving monitoring

(including drug resistance) for the TB/HIV program, and implementing TB infection control measures.

BACKGROUND: Over the last two years, the North East department, located at the border with the

Dominican Republic (DR) has been becoming an area of major focus for the United States Government

(USG) and other donors such as Global Funds (GF). Because of intense migration, trade and a melting pot

situation in this area, there are more and more concerns of a situation of rapid progression of HIV/AIDS in

this area. In1989 the MOH signed an agreement with CDS according to which CDS directly managed MOH

health infrastructures and personnel in a network of health centers located in the NE, North and West

Departments. In 1994 CDS signed a subcontract with the MOH in order to implement and supervise

TB/DOTS activities in the entire NE Department. With the President's Emergency Plan for AIDS Relief

(PEPFAR) resources, the USG has built on CDS network of primary health care and TB services to expand

HIV care including CT, palliative care, ARV as well TB/HIV.

So far, CDS has been able to integrate TB screening, prophylaxis and treatment in its network of HIV sites:

La Fossette in the North, Fort-Liberte and Ounaminthe in the North East. In addition efforts are being taken

with existiting resources to integrate CT and basic care in two TB sites with no HIV services in the NE

Department and to establish referrals between the other TB sites and the HIV sites to ensure that all TB

patients detected in the NE department get access to CT and HIV basic care and treatment services. Since

the monitoring system of TB/HIV program is weak, it is now difficult to establish the results of these efforts.

With fiscal year (FY) 2009 resources, the TBD will continue to build on CDS TB and HIV networks to

expand and reinforce TB/HIV services. Three additional TB sites with no HIV services will be reinforced with

integrated CT and HIV basic care services to bring the total to five in the NE department. As the CDS HIV

network sites will be expanded to 8, all of these sites will be reinforced with TB screening, prophylaxis, and

treatment capacity. In addition, the TBD partner will continue to play a major role in policy development and

in supervision, and quality assurance/quality improvement (QA/QI) of the program through the CDS network

of HIV and TB sites. This TBD will be funded under a direct Cooperative Agreement (CoAg) with the

Centers for Disease Control and Prevention (CDC) in concert with other program activities, specifically CT,

palliative care.

Expected results: Through the CDS network, the TBD will provide access to HIV screening services to

about 700 new TB patients (representing about 7% of expected TB patients nationwide) We expect that

28% (200) will be HIV positive and will enroll in care while 14% (100) will enroll in ARV.

Activity 1: TBD will allocate resources to support service organizations at 5 TB sites (including 3 new) in the

CDS TB/DOTS network. These resources will be used to hire human resources personnel (counselors,

physician, community and social workers), reinforce infrastructure to deliver counseling services as well as

HIV palliative care, at each site. These personnel will be trained at GHESKIO. TBD will work with GHESKIO

and Partnership For Supply Chain Management (PFSCM) to reinforce laboratory capacity at each site to

perform routine testing and cluster differentiation 4 (CD4) testing to detect co-infected patients in need of

ARV. These five TB sites will be part of the palliative care network sites that will benefit support for lab

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

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

of 8 HIV sites, the TBD will provide resources to support TB screening and diagnosis capacity including

purified protein derivative (PPD), chest X-rays and sputum smears as well as training of health

professionals in TB screening and prophylaxis.

Activity 2: The TBD will establish linkages between the 5 targeted TB sites and ARV sites in its catchment

area to ensure continuum of care for co-infected patients in need of highly active anti-retroviral treatment

(HAART). TBD will also establish referrals between the other TB clinics where HIV services are not

integrated and existing CT sites to allow access to HIV screening for all TB patients detected in the North

Department at all TB sites TBD will allocate resources to cover transportation costs as well as

accompaniment for these patients to the referred centers.

Activity 3: TBD will reinforce the HIV and TB supervision team to monitor and supervise the TB/HIV

program. Resources will be used to train this team in TB/HIV thru GHESKIO and to support its travel costs

to the different sites.

Activity 4: TBD will participate in all national efforts to elaborate and review the norms, protocols, guidelines,

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

monitoring of the program, and of TB drug resistance. Resources will be used for the dissemination of these

documents through the network. TBD will be responsible for implementing and monitoring infection control

measures in the managed sites according to the national norms and guidelines. TBD will also participate in

the national TB drug resistance plan by allocating resources to the network for tracking of suspected TB

drug resistance cases, collection of sputum specimens from these cases and processing of these

specimens to the national lab for TB culture and resistance testing.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18705

Continued Associated Activity Information

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

System ID System ID

18705 18705.08 HHS/Centers for To Be Determined 7716 7716.08 HIV/AIDS

Disease Control & Clinical Services

Prevention

Table 3.3.12:

Centre de Developpement de Sante (CDS) has been a PEPFAR sub-partner under the Management

Sciences for Health (MSH) umbrella since the inception of the Emergency Plan. As this NGO has

successfully supported Counseling and Testing, Palliative Care and Anti-retroviral Treatment services at

several sites, the USG team recognizes the need to directly fund the activities supported by this NGO.

Steps have been put into place for a follow-on TBD partner to continue these activities.

With Fiscal Year (FY) 2009 resources, TBD will support the national effort to strengthen and expand

voluntary counseling and testing (VCT) programs in the North East Department of Haiti building on the

successful implementation of two major VCT sites in this department and one in the North Department. TBD

will work with the Ministry of Health (MOH) to implement other VCT sites mostly in the western part of the

North East Department where the need for HIV programs is critical, and strengthen five former VCT centers.

TBD will collaborate with the MOH in building an efficient referral system to create a network for the HIV

program within the North East Department. Additionally, it will implement an anti-retroviral (ARV) service

program in Lafossette, reinforce the ARV sites in Fort Liberte and Ouanaminthe, the VCT site at Petit Place

Cazeau and implement VCT activities in La Saline (two shantytowns in Port-au-Prince). TBD will also

participate in the improvement of guidelines and tools related to the national HIV program.

Through partnership, CDS has been managing several public health care centers in the North East

Department, one in the North Department and two in the West Department for many years. More recently,

CDS has implemented and supervised the TB and malaria programs in the whole North East Department.

TBD is expected to have as large an experience in community and primary health care to be able to assist

MOH in developing comprehensive and integrated HIV program at the departmental level.

For the past three years, CDS has administered rapid HIV tests to 10,682 people in the North East

Department and 1,031 have tested positive for HIV. From January through June 2007, 400 people tested

positive for HIV among 3,747 tested at the two VCT sites in the North East and one in the North managed

by CDS. Of those enrolled in CDS's HIV care program in Ouanaminthe, Fort Liberte and La Fossette, 28 %

tested HIV in 2005 and 2006 and 74% tested HIV positive between January and June 2007. TBD will be

expected to continue performing at this level.

With resources from the President's Emergency Plan for AIDS Relief (PEPFAR), TBD will implement one

ARV site and five additional VCT sites with palliative care and HIV/TB programs and reinforce existing VCT

and ARV sites. All 10 VCT (including three ARV sites where the complete package is offered) will have an

integrated HIV program with counseling and testing services, palliative care (at the facility and in the

community), a PMTCT program, and a TB/HIV and community sensitization program.

Expected results

TBD is expected to test 25,000 people, including pregnant women, for HIV. TBD may expect three percent

of those tested to be HIV positive; hence, TBD may expect to enroll 700 patients in the palliative care

program and to place 200 on ARV treatment. Seventy (70) health care professionals will be trained in

counseling, testing, and palliative care and ARV treatment. In addition, seven new public health care

centers will be reinforced with trained staff, materials and equipment, and will be able to offer better services

to the community.

Activities

Activity 1

TBD will hire and train staff for seven VCT sites and one ARV site. This includes counselors, physicians,

pharmacists, social workers, nurses, lab technicians, and community workers. It will reinforce physical

infrastructure (especially laboratory) and provide materials and equipment at Trou du Nord, Mombin

Crochu, Terrier Rouge, Grand Bassin, Mont Organise, La Saline, and Petite Place Cazeau. It will also

completely staff the facility at La Fossette, which will become an ARV site. TBD will support counseling and

testing activities, TB screening (including sputum, PPD test), TB prophylaxis and treatment, opportunistic

infection prophylaxis and treatment, and psychosocial services at each site, x-ray and ARV treatment at the

ARV sites within its network. Supply Chain Management System will provide laboratory supplies and drugs.

Activity 2

TBD will help MOH in establishing an efficient referral system that will link all VCT, TB/HIV, and ARV sites

as well as all of the other sites that provide social support to PLWHA and their families. This network will

allow all partners and/or coworkers to share experience and build a comprehensive and integrated

departmental HIV program in the North East.

Activity 3

The central and regional TBD staff will monitor and supervise the HIV program. TBD will support staff costs

for travel to the different sites.

Activity 4

TBD will participate in all national effort to elaborate and review the norms, protocols, guidelines and others

tools for the HIV program.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18958

Continued Associated Activity Information

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

System ID System ID

18958 18958.08 HHS/Centers for To Be Determined 7716 7716.08 HIV/AIDS

Disease Control & Clinical Services

Prevention

Table 3.3.14: