The International Training and Education Center for Health (I-TECH) is a collaboration between the University of Washington and the University of California, San Francisco. I-TECH's activities occur primarily in the following technical areas: health system strengthening; health workforce development; operations research and evaluation; prevention, care, and treatment of infectious diseases. I-TECH has been working closely with the Ministère de la Santé Publique et de la Population (MSPP) and partners since 2004, at first to increase clinical skills and strengthen technical capacity related to HIV/AIDS, and in recent years evolving to support broader health systems strengthening as endorsed by PEPFAR and the Global Health Initiative. I-TECH supports activities that impact all departments in Haiti, primarily through training capacity building (pre-service and in-service), clinical mentoring (3 hospitals in Port-au-Prince), laboratory systems strengthening, and strategic information systems (electronic medical records, laboratory information system, and training database). I-TECH has identified several methods to increase cost efficiency. Infectious diseases training for nurses and Doctors will continue to improve quality of care for HIV patients, TB patients and other. Transition to local ownership will also reduce I-TECH costs in the long term. Transition plans are underway or in planning stages for all program areas. Strategies include identification of local partners (usually MSPP and current subcontractors), joint planning, building capacity through training and 1:1 mentoring, integration of curricula, phased transition of responsibilities, and ongoing on-site and remote technical assistance as needed.

During the last fiscal year, the community health course was revised by Institut Haïtien de Formation en Sciences de lEducation (IHFOSED) in collaboration with I-TECH to support the appropriate linkages and referrals to the health system. I-TECH will subcontract to INHSAC to train 100 health agents with the updated version of the curriculum (one session of 10 days).

In COP11, I-TECH collaborated with the MOH and partners to develop a TB curriculum. The basic content was based on the Caribbean Guidelines for the Prevention, Treatment, Care and Control of Tuberculosis and TB/HIV (from the CHART Network). During FY 2012 I-TECH will conduct five training sessions for 120 nurses and physicians working in the public health facilities and networks supported by PEPFAR. Clinical mentoring tailored to TB management, TB/HIV co-infection will be provided to three sites (La Paix, MIJ, and HUEH).

I-TECH will provide trainings for clinical laboratory personnel to support performance and operations improvement. Trainings will focus on quality system essentials, including health management information systems (including OpenELIS lab system), documents and archives, and evaluation. I-TECH will provide technical assistance to the MSPP National Public Health Reference Laboratory (LNSP) in collaboration with other stakeholders to have a broad approach laboratory quality essentials focusing on HMIS, documents and archive and evaluation. I-TECH will collaborate with LNSP in the elaboration of lab protocols and SOPs, and support curriculum design for teaching the protocols. After conducting the fingerprick pilot for specimen collection for VCT, I-TECH in conjunction with the lab stakeholders (SCMS, LNSP, CHAI) will roll out the technique nationally.

I-TECH will assist LNSP in conducting training to roll out proper practices of fingerprick specimen collection for HIV testing and other lab tests. Currently many laboratories refuse to use fingerprick, and others are using fingerprick without any standards. A pilot was conducted in 6 sites during COP11 and standardized lab procedures have been developed to perform fingerprick in country. A training session will be done in every health department (10 trainings) for the personnel of the VCT sites including lab technicians and nurses. I-TECH will collaborate with the LNSP to train non-laboratory staff to perform testing in order to effectively meet VCT demands and provide high quality VCT services to clients. A number of site visits will be conducted jointly with the LNSP and CHAI to follow up on proper utilization of the fingerprick. All the health departments will be visited, a total of 10 visits of 3 days during COP12. This collaboration will be helpful for the evaluation of the PIMA CD4 count using fingerprick.

I-TECH will help to convene a Technical Working Group for the elaboration of the action plan and a monitoring system to follow-up with implementation of the strategic plan. I-TECH will also engage a consultant to support the MOH (MSPP) to develop and implement laboratory policies based on its National Strategic Plan for Laboratory, released in July 2011.

I-TECH will also assist and provide direct technical assistance (Jacmel, Jérémie, HUP, NPFS, and 2 others designated) to become lab centers of excellence and adopt best lab operation and management practices, including implementation of a cost recovery model.

I-TECH will continue improvement and expansion of iSanté (EMR) functionality to serve patient data management needs according to priorities set by MSPP and CDC. Implementation of iSanté for primary health care will continue, increasing the number of sites successfully using iSanté for HIV/AIDS and primary health care to a total of 69 sites. I-TECH will assist with hardware and software deployment that supports uninterrupted iSanté use, and will mentor IT and SI staff to maintain the system. I-TECH will also provide training and mentoring to ensure high-quality data entry and use of data from iSanté to inform program and service improvements and expansion. New development will focus on supporting features and functionality started in COP11 (malaria fields/reports, TB module and reports, HealthQual reports).

I-TECH will assist MSPP to develop a health information systems framework and explore appropriate architecture; develop a revised reporting framework; mentor MSPP/CDC staff in system administration, software development, and technical writing; support MSPP/CDC staff to develop new features; and support MSPP/CDC staff to manage the rollout of new releases and functionalities. Development will focus on improved interoperability with other systems including OpenELIS, electronic dispensing tool (EDT), MESI, and OpenMRS; updating of HIVQual and HealthQual reports; expansion or adjustment of TB and malaria components; and other new features as identified by stakeholders. I-TECH will resume assistance provided in the past to sites for data quality improvement and use, by visiting PEPFAR-supported sites with printed reports from the EMR to devise and implement improvement solutions adapted to local conditions. The data quality improvement team will also provide online support to the sites by checking available reports from the EMR and establishing regular conference calls with local teams. I-TECH will work closely with identified counterparts from MSPP/CDC to begin transitioning development tasks.

In the lab sector, I-TECH will extend implementation, training and support for OpenELIS to 20 new sites for a total of 60 sites (overlapping those sites using iSanté for primary care). Support will include site visits and training, remote and in-person technical support, and hardware/infrastructure support as needed. I-TECH will also support an additional 20 sites to begin using the paper-based OpenELIS forms. I-TECH will continue to improve and expand the functionality of OpenELIS for clinical sites and LNSP according to priorities set by the Laboratory Information Systems Working Group. Development will include decision support tools, interfaces with automatic analyzers and a system for software bug fixes and updates for LNSP and the clinical sites. New features will include reinforcing the inventory system to meet SCMS needs, developing more QC/QC features to support EQA program at LNSP.

I-TECH will support MSPP to take over management of TrainSMART, and build MSPP capacity to provide ongoing training and support to the health departments. Through site visits and remote support, I-TECH will provide technical assistance to TrainSMART users to improve data quality.

I-TECH will continue its collaboration with CIFAS (the Center for Information and Training in Health Administration, located at HUEH), to continue to provide 3-week theoretical and practical training sessions using the revised national ART curriculum for junior and mid-level providers. TA visits to Mirogoane, Carrefour, Croix des Bouquets, and other sites as requested by CDC and MSPP, for HIV/AIDS services will continue.

I-TECH will continue its nursing initiative at HUEH, HUP, and MIJ with the goals of enhancing the role of nurses within the HIV care team through training advanced practice nurses in a one year intensive course including didactic and practicum components, to reach 15 nurses. Following training, these infectious specialist nurses will be capable of providing primary clinical management of stable HIV patients, TB patients and other common infectious diseases in Haiti. I-TECHs HIV nurse mentors will continue to collaborate with nursing supervisors at HUEH, HUP, and MIJ to deliver theoretical training sessions on HIV patient management, patient education, nutrition, and other topics and will supervise practical rotations. I-TECH will work with 2 nursing schools and university-based hospitals to include the training as a Continuing Education course. I-TECH nurses will also continue to work with the leadership at HUEH, HUP, and MIJ to evaluate the role of nurses relative to care protocols and patient flow patterns in order to optimize the level of nurse responsibility and improve patient care.

I-TECH will continue to support MSPP to develop a 4th year of the ENI curriculum and develop a competency-based, comprehensive pre-service teaching package. I-TECH will develop and conduct a training-of-trainers (TOT) based on the Teachback methodology on the new curriculum and provide support to MSPP and schools to implement it. I-TECH will continue to facilitate a nursing school working group to develop and validate standard student evaluation tools and processes, linked to graduation requirements.

I-TECH will provide guidance to the lab curriculum working group on the implementation of a 4th year curriculum for lab technicians; continue to host quarterly faculty development workshops to address key competencies for laboratory educators; provide resources to support recruitment of teachers and professional development for the national laboratory schools.

I-TECH will continue to empower general physicians by training 12 physicians from sites in remote areas on a newly adapted curriculum to become mentors. They will receive a refresher course on the more current pathologies encountered and in-depth training on management of HIV.

I-TECH will continue to provide assistance to the midwifery school to integrate HIV content into their programs and support training at the school.

I-TECH will continue to provide technical assistance to the Training Cluster within the MSPP Coordination Unit for AIDS/TB/Malaria on developing clinical training materials, TOT, and monitoring and evaluating training.

In COP11, I-TECH provided refresher courses on Primary Care for nurses and physicians to support the deployment of iSanté for public facilities and network supported by PEPFAR in 5 health departments. In COP12, the training sessions will continue to have a national coverage.

I-TECH will continue to subcontract with INHSAC to continue implementing its training in voluntary counseling and testing (VCT) (including rapid testing). INHSAC will conduct four VCT trainings for 100 participants in clinics and community-based VCT settings. INHSAC will also continue its training for psychologists, social workers and other key personnel at clinics, community-based care and treatment organizations on psychosocial support for people living with HIV/AIDS (PLWHA). The trainings will be held for 120 participants, and will include four days of practice at Hôpital Universitaire La Paix. To support epidemiologic surveillance and case notification, the trainings will also include one day for data management (in collaboration with METH SA), and one day for case notification (in collaboration with NASTAD).

Cervical cancer is highly preventable when caught in the pre-cancer stage, and safe and effective treatment is available even in low-resource settings. However Haiti does not have a standardized cervical cancer screening program. During FY 2011, in collaboration with the MOH, I-TECH participated in a training of trainers related to VIA technique and cryotherapy, where 23 people were trained as master trainers. The purpose was to pilot the screening and prevention program in 2 sites in collaboration with PAHO and JHPIEGO. By the end of the COP 11 period I-TECH will have supported another training session on LEEPS procedure and will have established at least one screening site in our network.

During FY 2012, I-TECH will work with the MOH to adapt, and disseminate new guidelines, clinical algorithms and referral pathways for screening of pre-cancerous lesions of the cervix and invasive cancers. I-TECH will also adapt iSanté to track cervical cancer-related indicators, including service provision data, to begin to collect cervical cancer morbidity and mortality data as a part of iSantés integration into primary health care services. I-TECH will also support the implementation of screening and treatment of precancerous lesions at the sites where they are providing direct financial and or technical assistance (Jacmel, Jérémie, NPFS, MIJ, HUP, and Carrefour).

In 2011 I-TECH facilitated the creation of a Positive Prevention (PP) technical working group (TWG) with representatives from MSPP, FHI, JHPIEGO, POZ, MSH, INSHAC, and I-TECH to adapt the PP model developed by the University of California San Francisco (UCSF) to the Haitian context. I-TECH subsequently developed and piloted a PP curriculum for health care workers; conducted training-of-trainers (TOT); and PP was implemented in 3 sites, MIJ, La Paix and Carrefour. In COP12, I-TECH will continue to support the 3 sites, extend PP model to other sites such as NPFS, Hôpital St Antoine and Hôpital St Michel. Five regional training sessions on PP will be held for 3 three health departments (Nord, Sud, and Ouest). The target will be nurses, psychologists, social workers, and case managers working in 50 sites for a total of 200 providers from all ART sites. I-TECH will also support INHSAC to integrate PP in their other curricula such as VCT training for social workers and psychologists, case manager training, and HIV care and treatment.

INHSAC will conduct trainings in Family Planning for 40 participants. The Family Planning training targets nurses and physicians working in the public health sector and networks supported by PEPFAR.

I-TECH will partner with Institut Haïtien de Santé Communautaire to deliver training and practicum experience for health care workers and community health workers. In recent years, INHSAC has provided training to hundreds of personnel from VCT/PMTCT scale-up sites in Haiti. INHSAC will continue this activity to reach personnel at new scale-up sites, and will provide follow-up supervision to reinforce transfer of learning into practice. Activities will include one week of theoretical training at INHSAC and a second week of practice in Maternité Issaie Jeanty plus three additional days for NASTAD, METH SA and EMR session. The PMTCT curriculum has been updated to include content on Mothers Clubs and Case Managers Strategies. It will emphasize patient flow (mothers and babies); links to service organizations to support mothers and babies, as well as the referrals between the different units (ANC, Delivery, Pediatrics) to ensure appropriate care and reduce loss-to-follow up; education of women enrolled in PMTCT program and their accompagnateurs; and use of data collection forms. A total of 4 PMTCT trainings will be realized, for a total of 100 health care providers trained.

In COP10, INHSAC developed a PMTCT Case Manager curriculum targeting case managers who will be responsible for: in-depth community education; working with women to develop a delivery plan; ensuring adequate institutional and community support for HIV-infected women during pregnancy and delivery; and reinforcing proactive management of HIV-infected pregnant women and their infants. In COP11 INHSAC began conducting this training, which will continue in COP12 with a total of 3 sessions reaching 60 case manager participants.

Through the placement of clinical mentors at three hospitals in Port-au-Prince (Hôpital Universitaire de la Paix (HUP), Maternité Issaïe Jeanty (MIJ), and Hôpital de l'Université d'état d'Haiti (HUEH)), I-TECH will continue to lead improvements in quality of care and access to HIV services. Clinical mentors will complete patient rounds, chart reviews, case conferences, and quality improvement projects with HUEH leadership, residents, interns, and/or medical students in the infectious disease unit and the adult unit of HUEH, with emphasis on primary health care, ART management, prevention of OIs and STIs. I-TECH will support 1) HUP to expand HIV services reaching 1980 adult patients in care/880 adult patients on ART; 2) MIJ to expand to 1100 in care/440 on ART; and 3) HUEH to expand to 4000 in care/1690 on ART. I-TECH will continue to offer its warmline telephone service to provide expert clinical advice on HIV/AIDS management to health care providers with limited access to on-site consultation.

I-TECH will support these sites to strengthen ART services to ensure early initiation of ART. Strategies to speed the enrollment process of eligible patients without compromising adherence will be implemented. Patient enrolled in care will be prepared for ART starting the first clinical visit.

Last year 10 Continuous Quality Improvement (CQI) projects were completed at four sites (HUP, MIJ, HUEH and Hôpital Carrefour). The CQI process involves analyzing iSanté EMR data to identify challenges, solutions and improvements to service provision. In COP12, CQI activities will continue at the 4 sites.

In COP12, Nos Petits Frères et Soeurs (NPFS) will expand its cohort of pediatric HIV patients at Hôpital Saint Damien to approximately 800 patients with 350 on ART. NPFS provides services including clinical monitoring of infants and children with HIV, hospitalization, daily directly observed therapy (DOT) for PMTCT for pregnant women with severe adherence challenges, monthly home visits for infants and children on ART, psychosocial support services, nutrition support, and referrals for economic support, educational services and other community-based programs. NPFS refers pediatric patients to other care centers closer to their homes for ongoing outpatient treatment.

NPFS will offer PMTCT service to 40 HIV infected women. 80 infants exposed to HIV (from the PMTCT cohort) will be screened with PCR-DNA for HIV and enrolled in care and support. 120 infants exposed and uninfected but vulnerable will receive pediatric care. As a national center of excellence, NPFS will train four physicians and six nurses to take care of infants, children, and adolescents exposed and infected with HIV/AIDS to scale-up the pediatric management of HIV/AIDS throughout Haiti. In Tabarre, 10,000 residents in twelve neighborhoods, under the leadership of a public health nurses and seven health agents, will participate in a health education program covering IMCI for children, reproductive health, HIV/AIDS, sanitation and vector control for the prevention of malaria, dengue, and filariosis. 200 children under one year of age will receive a full set of immunizations. 200 children aged one to five will receive full immunizations. 200 women of reproductive age will receive immunizations against tetanus through monthly assembly posts and at the institution. 100 women will receive a Pap smear to screen for cervical cancer. 100 women will with HIV whose children are included in HSD cohort will receive a method of family planning. I-TECH will provide technical assistance to NPFS to evaluate and assure quality of this practicum-training program.