The National HIV Quality of Care (HIVQUAL) program is a capacity building initiative using a framework for

quality management linking three core components: performance measurement, quality improvement (QI)

and quality management program. HIVQUAL-International in Haiti (HIVQUAL-H) is executed under the

leadership of the Ministry of Health (MOH) in close collaboration with the Centers for Disease Control and

Prevention (CDC)-Haiti for program management and technical support with input and assistance from

partners represented in the HIVQUAL National Committee. From its inception, the program developed a

clear model for knowledge transfer. Early implementation involved the training and mentoring of the

HIVQUAL core team, which includes MOH, CDC-Haiti and the International Training and Education Center

on HIV (I-TECH) staff. Training and mentoring of the team by the United States (US) HIVQUAL (HIVQUAL-

U) staff incorporated participation in a Training-of-Trainers (ToT) session in the US, Study Tours in New

York (NY) as well as intensive sessions in Haiti, with co-lead visits to pilot sites. Under guidance from

HIVQUAL-U, this core team then trained staff from departments represented by clinics selected for the pilot

phase of the program. Progression of HIVQUAL-H will be led by the core team under mentorship from

HIVQUAL-U. The team will ensure the spread to other clinics through training and mentoring of additional

departmental and key clinics' staff. Structured instruction includes: additional ToTs and study tours to the

US and consultation regarding resources and training. It is expected that once the program is spread to

incorporate all clinics in the country, the oversight infrastructure previously described will enable the

program to be sustained with minimal support from HIVQUAL-U. The HIVQUAL-H program will continue to

function under the auspices of the MOH with ongoing advice from the HIVQUAL National Committee and

through the execution of the core team. The core team will continue to provide support and mentoring to

department staff, which in turn will continue to serve as coaches to clinics.

BACKGROUND: The HIVQUAL-H program is executed under the leadership of the MOH in close

collaboration with CDC-Haiti for program management and technical support and with input and assistance

from implementing partners represented in the HIVQUAL National Committee including: AIDS Relief,

Catholic Relief Services (CRS), Haitian Group for the Study of Kaposi's sarcoma and Opportunistic

Infections (GHESKIO), Family Health International (FHI), International Training and Education Center on

HIV (I-TECH), Management Science for Health (MSH) and non-governmental organizations (NGOs), Institut

Haïtien de l'Enfance (IHE) and Partners in Health (PIH). Between fiscal year (FY) 07 and FY08, a core team

was established for the program which includes MOH, CDC - Haiti and I-TECH staff. The core team

participated in quality management (QM) and ToT sessions and in turn, organized and delivered a large

scale training session of regionally-based departmental staff and key staff from pilot sites. Adult care and

treatment, prevention of mother-to-child transmission (PMTCT) and pediatric indicators were introduced to

20 pilot sites, which included referral hospitals, department hospitals, and community health centers (CHC).

Data are mostly collected through the national Electronic Medical Record (EMR) from pilot sites and was

aggregated and distributed for benchmarking. Staff involved in HIV care at each pilot site was trained by the

core team and departmental staff in QM. Departmental staff continued to support pilot sites through TA and

coaching to ensure the sustainability of their QM programs. Starting in FY08, HIVQUAL partnered with the

PMTCT collaborative lead by Haitian Institute for Community Health (INHSAC) and MOH/National Plan.

Representatives from INHSAC joined the HIVQUAL National Committee and the core team with the goal of

encouraging sites to do QI projects on PMTCT. The second round of data collection will be completed and a

report issued with the program expanding to 60 clinics in FY08. Several QI trainings were completed in

addition to a ToT program.

In FY09, HIVQUAL-H will expand from 60 facilities to 120 facilities. Indicators measured through HIVQUAL-

H include patient retention, cluster of differentiation 4 (CD4) monitoring, eligible patients in ART, adult and

pediatric cotrimoxazole prophylaxis, treatment adherence, TB testing, nutritional evaluation, prevention with

HIV+ females and pediatric vaccinations.

Activity 1: The specific emphasis is at the clinic-level, adapting methods of QI to each organization's

particular systems and capacities. An assessment tool to measure the capacity of the QM program at each

facility is used and will measure growth of capacity while also guiding coaching interventions. HIVQUAL

has a unique and strong infrastructure component that emphasizes internal organizational growth and

systems development that aims to integrate QM into routine activities of care programs. Documentation

systems are enhanced through these activities leading to development of tracking systems that can improve

clinical monitoring of patients and retention in care.

Activity 2: Facility-specific data will be aggregated to provide population-level performance reports that

indicate priorities for national and regional QI activities. Both internal and external factors are identified that

can be improved: the former within the clinic and the latter by raising issues to the MOH HIVQUAL-H team.

Activity 3: HIVQUAL-H will continue to support regional and district networks of providers who are engaged

in QI activities fostering coordinated approaches to address challenges unique to each area, including, for

example, human resource shortages and coordination of care among multiple agencies and donors, as well

as community follow-up and adherence services.

Activity 4: Expansion in 2009 will progress to monitor pediatric in addition to the adult and PMTCT

indicators. A set of pediatric indicators will be selected and integrated in the data reports.

Activity 5: There will be focus on fostering consumer involvement in QM programs. Expansion facilities are

selected through a coordinated planning approach led by MOH and CDC-Haiti. Meetings of providers will

be held to share best practices and QI strategies.

Activity 6: Spread of coaching and mentoring led by the HIVQUAL-H core team will occur through intensive

support of partner organizations (e.g. I-TECH, GHESKIO) as well as USG partners (AIDS Relief) to promote

development of their agency-wide QM programs with guidance from the team. Sponsorship by department

officers will be encouraged. Additional QI training will be provided jointly with Haitian HIVQUAL-H partners

to adult and pediatric providers. Additional trainings and TOT programs will be supported as well as

requested work with organizations to expand the capacity of QI trainers within Haiti. The US HIVQUAL

team will continue to mentor the HIVQUAL-H team to deepen its skills to oversee QM programmatic

Activity Narrative: activities, evaluate the progress of the HIVQUAL-H program and recommend growth and improvement

activities to the HIVQUAL-H team.

Additional data collection from participating sites will occur, with generation of performance data reports, QI

project reports and comparative analyses. Indicators will be refined following data collection in consultation

with MOH and key stakeholders. John Snow, Inc. (JSI) has been contracted by Human Resources

International (HRI) as detailed in its scope of work to evaluate the work of HIVQUAL-International in

achieving its desired goals of building capacity for quality management. In FY09, HIVQUAL-U is expected

to reach 60 sites clinics and integrate more pediatric care and PMTCT services. Study tour to the US is

planned for a delegation from MOH and the HIVQUAL-H team. Travel support to an international QI

conference is planned to further the education of key staff in the methods and theory of QI in venues which

are not available outside of the US or Europe.

New/Continuing Activity: Continuing Activity

Continuing Activity: 19060

Continued Associated Activity Information

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

System ID System ID

19060 19060.08 HHS/Health New York AIDS 8343 8343.08 HIV/QUAL $300,000

Resources Institute

Services

Administration

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Safe Motherhood

* TB

Military Populations

Refugees/Internally Displaced Persons

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 10 - PDCS Care: Pediatric Care and Support

Total Planned Funding for Program Budget Code: $1,250,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

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 PLWHA 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 PLWHA 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 PLWAs 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

Haitien d'Etude du Darcome de Kaposi et des Infections Opportunistes (GHESKIO), Partners in Health (PIH), Ministry de Santé

Publique et Population (MSPP), AIDSRelief and Management Sciences for Health (MSH), International Child Care (ICC),

Fondation Pour La Samté Reproductive et l'Education Familiale (FOSREF), Promoteur Objectif Zero 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 CD4), patient monitoring tools (chart,

register), and regular supplies of laboratory commodities and drugs for opportunistic infections (OI). FOSREF and POZ are two

networks specialize 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. Linkages are being reinforced between palliative care services and ARV and TB services to ensure a continuum of

care to PLWHA 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, child survival, and maternal care.

Others like MSH/SDSH and AIDSRelief have built on existing community network 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, hire 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 Solution (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 PLWHA. All of the networks around ARV sites have taken steps to

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

attitudes and reduce stigma.

Since FY 07, the USG team has taken steps to address the limited access to socio-ecnomic services, food, and community

preventive care package experienced by PLWAs to date. In each of Haiti's 10 regional departments, a lead 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 to Fight AIDS, Tuberculosis and Malaria (GFATM) and the

Ministry of Health (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 PLWHA, by prescription, at the clinic. A plan of distribution has been put in place to

make this food available through different sites for malnourished PLWHA 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. 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 PLWHA thru the family centered approach with particular emphasis on: a) providing

shelter to PLWHA in need b) nutrition assessment, counseling and feeding support for clinically malnourished PLWHA as a

component of clinical care and treatment (Food by Prescription) and c) link with the OVC program for school fees support d)

leveraging with other NGOs involved in job creation and receiving USAID funds such as KATA and CHF, to provide jobs and

income generating activities to a greater number of PLWHA e) linkages with churches to provide more spiritual care to PLWHA

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. 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 (9100 being children)

Number of individuals trained in clinical care: 300

Number of individuals trained in community palliative care: 800

Table 3.3.10: