Partners In Health/Zanmi Lasante (PIH/ZL), in collaboration with the Haitian Ministry of Health (MSPP), provides comprehensive health care in rural central Haiti, including integrated prevention, care, and treatment services for HIV/AIDS/TB. Global Fund and PEPFAR support allowed PIH/ZL to scale up integrated programs to 12 sites in the Central Plateau and lower Artibonite regions, serving 1,202,979 people. PIH/ZL primarily targets women, the poor, and other marginalized groups. The comprehensive HIV program aligns with PEPFAR and GHI strategies for Haiti, including increased treatment and care at all sites and within at-risk populations, prioritization and integration of PMTCT services, increased pediatric care, and integration with other PIH/ZL and MSPP programs. The PIH/ZL partnership with the MSPP aims to strengthen Haiti's public health system. Eleven of 12 PIH/ZL sites are MSPP facilities. PIH/ZL invests in infrastructure, information management systems, and human resources at each site to build local and sustained capacity. To enhance quality of care and efficiency, PIH/ZL focuses on strong monitoring and evaluation. By linking our electronic medical records (EMR) system to the national database for HIV case notification, we are improving HIV surveillance systems and reporting. With improved program management, further integration of services, increased capacity of healthcare workers, and leveraging of partnerships, PIH/ZL is working towards greater cost efficiency. In early 2012, we plan to initiate a cost effectiveness analysis to strengthen this effort.

PIH/ZL works to optimize quality of life for HIV-infected patients and their families and to prevent transmission of HIV and other infections, now including cholera. HIV care and support activities are conducted within the comprehensive HIV program in the context of primary care, and are delivered by complementing a high standard of clinical care with a strong community-based network of accompagnateurs. Care spans from the clinic, to the community, to the home, and activities are carried out in all 12 sites we serve in the Central Plateau and lower Artibonite regions. HIV-infected patients and their families are the primary target population. As PIH/ZL engages more women in VCT activities, and generally works to focus efforts on women and marginalized groups, the proportion of women receiving care and support services is greater than men. In St. Marc, PIH/ZL specifically engages commercial sex workers, in addition to the general population in the comprehensive HIV program. As a routine part of ARV services, all patients receive daily home visits by their accompagnateur. These visits ensure client retention and needed referrals. In addition to daily directly observed therapy (DOTS) for patients on ART, the accompagnateur provides emotional and social support, monitors health and well-being, education and information and cholera prevention. If patients experience barriers to positive outcomes, the accompagnateur addresses the situation either directly or through a referral to a clinic. The PIH/ZL social work team provides monthly patient meetings, support groups, and individual psychosocial support. As needed, a prevention package (safe water, condoms, and insecticide-treated nets in areas where malaria is endemic) and food/nutritional support is provided for HIV-affected families. In 2012, 3,750 severely malnourished patients will receive nutritional support, and 7,000 clients will also receive food and/or other nutrition services to ensure food security. Additional social support may include assistance with school fees, housing, and transportation support to/from a clinic. In 2012, PIH/ZL expects to provide a prevention social support package to 11,000 PLWHA and transportation assistance for 5,600 PLWHA. Through local partnerships, PIH/ZL also works to link HIV patients with other economic assistance and social programs. PIH/ZLs Department of Monitoring and Evaluation tracks data on community-based activities and social support, in addition to comprehensive data collected at the health facilities. This data is part of a regular feedback loop for clinical and program staff, providing valuable input for monitoring and quality improvement.

To support HIV-affected orphans and vulnerable children (OVC) and their caregivers, PIH/ZL takes a family-oriented, rights-based approach to social support, focusing on meeting multiple needs including the provision of nutritional support, psychosocial support, and social assistance, in addition to clinical care. In the context of primary care, PIH/ZL supports the capacity of health centers to identify children infected or affected by HIV while providing services such as vaccinations and well-child visits. Dlo Lavi, bednets, ORS, and vitamins will be provided both in community-based home visits and clinic visits, as available. Community-based staff ensure adequate follow-up and growth monitoring of at-risk children to prevent relapse into malnutrition. Children identified as malnourished and severely malnourished are placed in PIH/ZLs nutrition program, where they will be prescribed locally produced ready to use therapeutic food (RUTF), Nourimanba, or a food supplement, Nourimil. It is expected that 7,000 OVC will receive food and nutritional support in 2012. PIH/ZLs trained social workers provide psychosocial support services to OVC and their HIV+ parents or caretakers. They offer support groups, as well as individual counseling for those who have not disclosed their HIV status. The psychosocial support groups focus on coping strategies for dealing with stigma, grief and loss; identification of depression; and disclosure of HIV status to family members. In 2012, PIH/ZL expects to enroll 450 OVC and caregivers in psychosocial support groups. Social workers also provide prevention education targeted at teenage girls and boys to reduce the chances of OVC themselves becoming infected by HIV or other STIs, or becoming pregnant too early. PIH/ZL expanded capacity to provide psychosocial support and services to OVC by providing social worker assistants in the lower Artibonite and training social workers for the newest sites.

In 2012, PIH/ZL will provide 12,000 OVC with school aid and other support. Recently, the PIH/ZL psychosocial team outlined plans for an OVC program evaluation. An initial data analysis has already been performed that resulted in use of new performance indicators and targets to improve integrated care for OVC.

Tuberculosis (TB) is the leading HIV-associated opportunistic infection (OI) for patients in Haiti, and is rampant among HIV positive patients and their families due to chronic malnutrition and overcrowded living conditions. Detection and treatment of TB is fully integrated into PIH/ZLs comprehensive HIV program. PIH/ZL has strengthened and expanded capacity to detect, treat, and prevent TB among HIV-infected patients across all sites. PIH/ZLs ultimate goal is to screen 100% of HIV-positive patients for TB. We are currently in the process of merging two formerly separate forms into the same intake form. This form will be rolled out in 2012, and with that in place we expect to screen 95% of new patients. We will screen 60% of existing patients in 2012 and increase that to 95% by FY2015. Of the 23,000 patients we expect in our HIV program in 2012, we expect 10%, or 2,300 to start TB treatment. Clinical guidelines adopted by PIH/ZL also recommend that all patients with tuberculosis be offered HIV testing and counseling. In 2012, we expect to test 100% TB patients for HIV. PIH/ZL trains clinicians and accompagnateurs on the management of TB/HIV co-infection on a regular basis. Select clinicians and community health workers from all sites will also participate in classroom-based trainings and clinic- and community-based practicums that address TB identification, treatment, and prevention strategies for HIV-infected individuals. PEPFAR funding also supports TB/HIV-related laboratory capacity and the maintenance of necessary infrastructure. The PIH/ZL Departments of Monitoring & Evaluation and Medical Informatics work to standardize data collection and evaluate programs for quality improvement. The M&E team not only collects data from health facilities and also from community based activities. On a weekly basis, the management, program, and clinical teams meet to review data and consider program adjustments.

PIH/ZL works to optimize the quality of life for HIV-infected pediatric patients and their families and to prevent the transmission of HIV and other sexually transmitted infections (STIs). These activities overlap with those under Pediatric Treatment (PDTX) as PIH/ZL provides comprehensive care and treatment in an integrated approach to improve outcomes. Care and support activities are conducted both through our health facilities and our community-based network of accompagnateurs. Activities will be carried out at all 12 sites. As a routine part of ARV services, all pediatric patients are seen daily in their homes by their accompagnateur. These visits provide adherence support and serve as opportunities to monitor outcomes and provide palliative services. If patients experience side effects, advanced disease, or other barriers to positive outcomes, the accompagnateur addresses the situation either directly or through a referral to a clinic. Social and psychological support to pediatric HIV patients and their families is provided based on needs assessments conducted by doctors and social workers. Access to food support will be provided for children in need. In 2012, PIH/ZL expects to provide social and psychological support to 235 pediatric HIV patients on treatment and their families PIH/ZL HIV-positive families with assistance for school fees, housing, food, and transportation to/from the health facility to further ensure food and economic security. The program will also provide links to microenterprise activities. In 2012, PIH/ZL expects to continue to provide social assistance to the approximately 235 pediatric HIV patients on treatment.

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PIH/ZL promotes human resources for health through numerous trainings, medical education programs and strengthening 11 MSPP health facilities. We invest in physical infrastructure improvements, equipment, information management systems, procurement systems, and laboratory services. Training takes place both within and outside of our National Training Centers in Cange and Hinche. PIH/ZLs Medical Informatics team is linking our electronic medical records (EMR) system and the national database for HIV case notification. We will adopt and integrate the indicators of the national EMR. In 2012, we will begin to roll out an upgraded EMR system linking clinics, pharmacies, and laboratories, and improvements to the Internet system. We will improve the interoperability of our EMR and link it with HEALTHQUAL to generate the appropriate reports. PIH/ZL collaborates closely with the National Alliance of State and Territorial AIDS Directors to improve HIV surveillance systems and reporting. PIH/ZL plans to strengthen procurement systems and laboratory services at all of its sites. In all of our work, PIH/ZL leverages partnerships to create a comprehensive and integrated approach to healthcare in Haiti. For the HIV program, PIH/ZLs key partners are the MSPP, PEPFAR, and GFATM. Additionally, the World Food Programme and several local NGOs collaborate with the HIV program. This year, the World Bank is supporting a new pilot program for polyvalent CHWs in Boucan Carre. The Canadian International Research Development Centre supports some EMR costs.

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PIH/ZLs efforts to prevent the spread of HIV and other STIs are grouped in four main components: education and outreach; radio-messages and large scale community-wide events; production and distribution of educational materials; and screening and treatment for sexually transmitted infections (STIs). These efforts specifically target marginalized populations of all ages including OVC, men who have sex with men (MSM), commercial sex workers, and women.The HIV prevention strategy includes access to family planning supplies and partner counseling. All communication and counseling strategies include abstinence, be faithful and use condoms as central messages. Prevention activities will be carried out at all 12 sites. Specialized community outreach workers (NEC) provide prevention education in schools, churches, market places, health centers, community meetings, mobile clinics, soccer games, brothels, traditional healers homes, and cock fighting arenas with people of all ages. Prevention messages are frequently broadcast on major radio stations throughout the Central and Artibonite departments. Prevention messages are promoted to the many thousands of people who attend the annual World TB Day and AIDS Day community events. PIH/ZL expects to reach 600,000 people in 2012 with prevention messages. PIH/ZL promotes and provides condoms free of charge at all health facilities, through mobile clinics and community events. Printed materials incorporate images to easily convey public health messages. By empowering both men and women to make informed choices about their sexual behavior, PIH/ZL sexual prevention activities work to increase gender equity in HIV/AIDS programs, address male norms and behaviors, and place an emphasis on the reduction of violence and coercion. PIH/ZLs Department of Monitoring & Evaluation tracks data on prevention messages and community-based activities. The data is regularly provided to clinical and program managers who monitor and evaluate programs.

PIH/ZL provides training, supervision, and services in comprehensive counseling and testing (VCT) and sexually transmitted infection (STI) detection and management. These VCT activities are conducted within PIH/ZLs four pillars model for implementing a comprehensive HIV program in the context of primary care: 1) HIV prevention and care, including VCT; 2) detection and treatment of TB and other opportunistic infections; 3) detection and treatment of STIs; and 4) womens health PMTCT services. VCT activities are carried out at all 12 sites. Specific target populations include adults and most at-risk or marginalized populations, particularly out-of-school youth, street youth, and migrants, as well as orphans and vulnerable children and people living with HIV/AIDS and partners. During the last 12 months, 66,696 individuals received testing and counseling services; in 2012, PIH/ZL aims to more than double that number to 147,358 . Comprehensive opt-out VCT services are provided in health facilities and via mobile clinics. At each health facility, pregnant women are offered VCT as part of routine prenatal visits. HIV VCT services are also offered to all symptomatic and at-risk individuals seeking care. This opt out approach to case detection integrated within primary care and womens health services has consistently proven effective for high uptake of HIV testing at our project sites. Mobile clinics, including three new mobile VCT clinics managed from Verrettes, are used to reach some of the high-risk groups including street youth and migrants, as well as the general population. Enhancing efforts to identify and treat pediatric HIV cases, PCR HIV testing will be provided for all orphans less than 18 months of age. For 2012 and beyond, PIH/ZL plans to increase pediatric and partner testing. In 2012, PIH/ZL will increase efforts to test partners of new pregnant women in our program. We are aiming for 20% of newly enrolled pregnant women have a partner tested in 2012, with a goal of increasing that over subsequent years.

PIH/ZL provides comprehensive PMTCT services to HIV+ women at all 12 sites. Mirebalais Hospital is expected to open in March 2012, and will include comprehensive maternal and child health services, with integrated PMTCT. As part of PIH/ZLs provider-initiated VCT strategy, pregnant women seen at PIH/ZL sites receive counseling (including family planning) and are offered HIV testing during routine prenatal visits. This is done on an opt-out basis. PIH/ZL enlists ajan fanm (community health workers trained in womens health) to increase referrals of pregnant women to clinics for testing and prevention education. In 2012, PIH/ZL expects to provide testing and counseling to 29,000 pregnant women. PIH/ZL also provides prenatal, perinatal, and postnatal care to HIV-infected women at each site. In the prenatal period, HIV+ pregnant women are enrolled in the PMTCT program for counseling on transmission prevention. If health workers discover that a woman has contracted HIV and/or become pregnant as a result of sexual violence, PIH/ZL staff connect her to legal services and provide ongoing medical and psychological support. ART is offered to women with advanced HIV infection and to all women in the third trimester of pregnancy. Nutritional supplements, multivitamins, and STI screening and treatment are also routinely provided. Mothers and infants receive comprehensive postnatal care with ART for the infant, ongoing ART for the mother (if required based on her stage of disease), education, and increased nutrition and home-based support to enable best feeding practices. In 2012, PIH/ZL plans to provide this comprehensive care for 512 HIV+ pregnant women. Post-partum, new mothers receive nutritional supplementation, infant formula, and supplies for preparation of clean water. It is expected that 512 new HIV-infected pregnant women will receive these services in 2012. As the MSPP recently adopted new (WHO) PMTCT protocols, PIH/ZL will provide staff training to ensure adherence to the new regimens. PIH/ZL will use positive deviance strategies to address anticipated cultural barriers to these new protocols.

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PIH/ZL administers integrated, comprehensive provision of care and treatment. As this is a continuum of care, these activities overlap with HBHC. At all 12 sites (Belladère, Boucan Carré, Cange, Cerca La Source, Hinche, Lascahobas, Thomonde, Petite Rivière, St. Marc, Montrouis, Verrettes, and Mirebalais), PIH/ZL maintains access to ARV services and antiretroviral therapy for HIV+ patients and to train health workers in all aspects of HIV care and treatment. As HIV+ patients are identified through PICT and VCT services, they are referred to our comprehensive HIV program for monitoring, care, and treatment. General clinical care is provided in the health facility, at home, and through mobile clinics. All HIV-positive patients are followed monthly by a trained HIV/TB physician. At each visit, patients are evaluated for HIV disease progression, TB and other OIs, and general health and well-being. When indicated, prophylaxis, treatment, and social services are provided; palliative care given; and ART provided. All patients who are placed on ART are assigned an accompagnateur (a community health worker), who provides essential psychosocial support to patients and their families in addition to daily directly observed ART. The accompagnateur also notifies clinic staff if a patient experiences side effects or new symptoms. All care and treatment is provided free of charge to the patient. In 2012, PIH/ZL expects to provide clinical care to 23,000 patients. PIH/ZL maintains services for 6,730 individuals currently on antiretroviral therapy (ART) through retention efforts and clinical follow-up. In 2012, PIH/ZL expects to enroll 1,404 new patients on ART. PIH/ZL will seek to increase enrollment among the most marginalized and high-risk groups in its catchment area, including commercial sex workers, men who have sex with men, out of school youth, and migrants. In addition to providing direct services, PIH/ZL is committed to expanding the capacity of individuals and organizations in Haiti to initiate and manage ART treatment, avert new HIV infection, and provide care for an increased number of HIV positive patients. We train healthcare workers across Haiti, including pre-service trainings and in-service trainings. In 2012, PIH/ZL expects 60 health care workers and 250 community health workers to complete a pre-service training program, and another 500 health care workers to complete an in-service training program. Both these training programs, and PIH/ZLs partnership with the MSPP, contribute toward building local ownership and sustainability of ART service delivery. In early 2012, PIH/ZL will convene an internal task force to evaluate if services can be delivered differently and more efficiently given the number of years patients have been treated.

Pediatric treatment efforts include access to antiretroviral therapy (ART) for existing pediatric patients, expanding access to anti-retroviral (ARV) services to additional HIV-infected children, and training health workers in all aspects of pediatric HIV care and treatment. Through a comprehensive approach that coordinates efforts through health facilities, mobile clinics, and community health workers, PIH/ZL ensures program retention and clinical follow-up. All symptomatic or at-risk children and pregnant women seeking care at PIH/ZL clinics are offered VCT. If identified as HIV+, a patient is referred for post-test counseling, CD4 count and other lab tests. All HIV+ pediatric patients are followed monthly by a trained HIV/TB physician. At each visit, pediatric patients are evaluated for HIV disease progression, with viral load monitoring for both pre-ART or ART patients, for tuberculosis and other opportunistic infections, and for general health and wellness. When needed, prophylaxis, treatment, and social services are provided; palliative care given; and ART initiated. Early detection of HIV assures the child receives proper treatment and nutrition as quickly as possible. Every child in PIH/ZLs PMTCT program receives 2 PCR tests along with rapid tests at 0, 3, 6, 9, 12 and 18 months to confirm a childs HIV status. PIH/ZL provides community-based VCT services as well as general clinical care for HIV-infected children and their families through mobile clinics; and pediatric patients are assigned an accompagnateur who gives essential psychosocial support to patients and their families, monitors health, and provides daily directly observed ART. In 2012, PIH/ZL expects to provide care and ART services for approximately 235 pediatric HIV patients. All care and treatment is provided free of charge. PIH/ZL conducts ongoing training of clinical staff in effective palliative care strategies specifically focused on children.