The Haiti Project of the University of Miami Miller School of Medicine provides technical assistance and supervision for the comprehensive HIV/AIDS program established at Hôpital Universitaire Justinien seven (7) years ago. Hôpital Universitaire Justinien has been designated as one of the Centers of Excellence of the National HIV/AIDS program for the northern region of Haiti. This challenge implies a transition from an initial contribution in the context of the emergency response to the HIV/AIDS epidemic to a sustainable, effective and strategic role in this part of the country in line with the Pepfar strategy . The following components are part of the existing program at Hôpital Universitaire Justinien and are receiving close support and guidance from the Haiti Project's team: The Adult Care, Support and Treatment; The Pediatric Care, Support and Treatment; The HIV Testing and Counseling; TB/HIV combined infection; and the Health System Strengthening. One important contribution of the Haiti Project of the UMMSM is the development of HIV/AIDS educational activities for healthcare personal in the Northern area of the country and the establishment jointly with Hôpital Universitaire Justinien of a Continuing Medical Education Center for HIV/AIDS care. This intervention is critical for the implementation of safe, effective and quality care to the PLWHA in the northern area of the country. Empowerment of local leadership as well as the overall strenghtening of facilities in the HIV/AIDS centers of the northern part of the country is central to the capacity building initiatives of the Haiti Project of the UMMSM.

HUJ has elected to integrate HIV care in the services of the institution. The Family Practice Center and the Preventive Medicine Unit of the hospital share the responsibility of providing a comprehensive package of ambulatory care and support to the enrolled patients. A bio psychosocial model is applied to the care of these patients. Patients with serious complications of their HIV infection or other acute medical problems requiring hospital admission receive their medical care on the Internal Medicine ward.

As per September 2011, a total of 1,974 patients were actively enrolled in the program, with 807 men and 1,167 women, benefiting from an array of services which include: comprehensive clinical care with available essential medicines , preventive interventions ( TB prophylaxis , cotrimoxazole prophylaxis), nutrition,family planning , psycho emotional support and social support. The community outreach arm of the program with the community health workers play a critical role for tracking of the patients from the pre enrollment stage to the post enrollment long-term adherence to care.

Prioritized strategies are currently implemented to increase at 80% the enrollment of patients tested positive for HIV and the retention of these patients in the system. These include:

- Strengthening of the psychological care unit to improve the quality of the psychological support

- Tracking of patients tested positive who didn't receive their test result and the post test counseling

- Fast track enrollment for all patients tested positive

- Tracking of enrolled patients with missed appointment

- Assignment of an "accompagnateur" to all new enrolled patients

- Establishment of additional support group (3) during this current fiscal year

- Availibility of transportation fee for all enrolled patients to come to their appointment

- Mandatory periodic medical visits at the Family Practice Center

Additional interventions are planned to strenghten the overall quality of care for ambulatory and hospitalized patients and the immunologic surveillance of the enrolled patients (availability of CD4 count tests for the patients twice a year). The Haiti Project has designed and implemented, through various training activities, a specific training component to improve ability of the providers to offer quality care to the enrolled patients.

Linkages with PAM, CHAMP, CBO are beeing strenghtened to create appropriate synergies beneficial to the patients Quality improvement cycle are used to for the continuous improvement of the enrollement and retention performance of the care system at HUJ.

Since 2006, 416 patients with TB/VIH combined infection have been diagnosed at HUJ. The current rate of completion of treatment (TB) is 73% with a mortality rate at 23%. Existing guidelines for the management of HIV/TB combined infection are very limited and not disseminated throughout the country. The clinical laboratory of HUJ performs more than 1000 sputum smears for TB diagnosis. However, laboratory capacity in support to the diagnosis and the monitoring of patients with TB is limited. There is no capacity to diagnose and treat drug-resistant TB, Currently at HUJ, 100% of HIV patients are screened for TB according to norms and all active TB patients are screened for HIV infection. Efforts have been initiated since last fiscal year to improve collaboration between the TB and HIV programs to optimize the care of patients with TB/HIV co infection as these patients are co managed by both programs.

Efforts were also initiated to reduce the risks of TB transmission at HUJ (identification and mitigation of risks)through infection control measures .

The Haiti Project of UMMSM is an active member of the national collaborative initiative with the other partners of the Ministry of Health of Haiti to design and promote through educational initiatives a National Curriculum for TB.

One one-site physician has been designated to receive additional training on TB clinical care and the National TB program to promote the best practices in TB care and program management. A University of Miami expert provide technical assistance (guidance/supervision/education) for the strengthening of the TB clinic, the linkages between the TB and HIV programs and the care of the patients with TB/HIV combined infection. These initiatives are coordinated with the TB technical office of the North Health Department.

The National TB and HIV M&E framework as well as the revised TB/HIV indicators will be incorporated in the Haiti Project M & E plan for the program.

Children diagnosed with the HIV infection receive their medical care at the Family Practice Center. Currently 120 children and adolescent are enrolled in care and support. Among these children, 100 are currently receiving ART HIV infected children receive comprehensive, continuous family centered and community oriented care. Children exposed to the HIV virus from a HIV positive mother are followed in the pediatric service for about six weeks. Currently, exposed children are under care in the pediatric service.

The national guidelines are used to provide care and support to the children diagnosed with HIV include: Comprehensive medical care, preventive measures (immunization, TMP prophylaxis), nutrition.

The program intends to increase the number of parents and HIV positive adolescents support groups. "Accompagnateurs" are provided to the children where the parents have difficulties with adherence to care. Linkages with community based organizations contribute in strengthening the care system for children and adolescents.

The Haiti Project has trained through a mini fellowship in pediatric infectious diseases one of the attending physicians at the Family Practice Center. This physician currently supervises the care to HIV infected children at Hôpital Universitaire Justinien. supervisory activities include: Chart review, monitoring of immunization in children, adherence to care and treatment.

UMMSM will strengthen the linkages between pediatric and PMTCT services to ensure that all HIV exposed new borns with PCR positive are put on ART.

The SI allocations reflect efforts in support of treatment and training activities that were previously captured under other budget codes. During the COP 2013 budgeting process University of Miami attributed program management, staff time and operational costs to this area and it is reflected in the budget code allocations.

The Haiti Project works collaboratively with the North Health Department office and Hôpital Universitaire Justinien for supervision and mentoring of existing HIV/AIDS centers in the region. The centers optimally receive six scheduled visits per year and additionalvisits are done as needed. In FY2012, UMMSM will strengthen and expand the HIV referal network in the North Department to ensure HIV patients receive high quality care the closest possible to their homes. This will also reduce cost and improve adherence.

One major challenge is to create more coordination and synergy between the North Health Department/HUJ/Haiti Project of UMMSM to optimize the benefits of the joint actions. The North Department plans to address these issues through periodic meetings and workshops with the partners.

The Haiti Project has developed jointly with HUJ a Continuing Medical Education Center for HIV/AIDS . The Center has been formally established in April 2010 although the Haiti Project has developed and implemented HIV/AIDS educational activities since 2006. Personnel from the HIV care centers of the North Health Department are routinely trained or retrained at the Center as HUJ serves as the main site for practical training .Innovative training activities have been developed by the Haiti Project of UMMSM team including the training of 30 HIV Nurse Practitioners during the past three years to serve the patients in the northern part of the country. Trainings also encompass wrap around areas as family planning, mental health and cholera and contribute to the global strenghtening of the health care system. A total of 900 participants have benefitted from the trainings activities designed, organized and implemented by the Haiti Project and HUJ. During COP 12 UMMSM will provide capacity building training on as-needed basis to health providers in the North Department, allowing them to meet all the health needs in the areas of TB, HIV, other opportunistic infections, and infectious diseases.

The Voluntary Counseling and Testing for HIV at HUJ has started 7 years ago with one point of service in the facility. During the past 3 years, 5 additional posts of HVCT have been established in the institution, increasing access to the patients and their family. The number of patients/clients tested has significantly increased recently. HUJ aims at educating and offering the counseling to 80% of the users of the facilities on HVCT through group education counseling sessions in different areas of the hospital. Currently HUJ is testing 10,000 persons per year including 150 TB patients and 3,000 pregnant women.

The national guidelines are used as the reference tool for counseling and testing for HIV. During the next two years, all the counselors (10) will receive formal training or refresher training on the guidelines for HVCT and an appropriate on-site system to monitor the quality of testing and counseling will be established (normative supervision). For FY2012, UMMSM will work with HUJ to implement rapid testing using fingerprick.

Strategies are currently implemented to increase the performance of the HVCT services with special attention to the productivity of these services. Additional space will be provided at the TB clinic for HVCT activities. The program will also educate and motivate all providers of the hospital to refer clients and patients to the HVCT posts in order to increase demand creation in this high-yield setting and reach high-risk populations using the services at HUJ. Strategies are also implemented to assure the enrollement of all patients tested positive: Same day identification of residence, enrollement in a tracking system, appointment at the earliest time possible, strenghtening of the referral system for patients referred to another point of service in the North Department Network (new care and treatment centers are being more available and may be closer to a patient's residence).

Efficiency of the laboratory HVCT services will be assessed as well as the current status of the laboratory workforce performing diagnostic for HIV infection. Hours of availability of lab services (afternoon shift) will be extended.

Existing tools of monitoring will be used to assess progression toward targets. The Haiti Project will work with HUJ, the North Health Department, the National Laboratory for quality assurance issues related to testing and counseling.

Over the next two years, HUJ will test 6,000 pregnant women for the HIV infection and syphilis which represent 100% of the pregnant women seen. It's estimated that 210 pregnant women will have a positive test for HIV and all these women will be enrolled in the PMTCT program during this current fiscal year and the following one . The current rate of completion of prophylaxis for pregnant women is currently around 45% and 40% have received their prophylaxis.

The main objectives for the next two years call for 80% of enrolled pregnant women to receive a complete course of prophylaxis and all exposed newborns from enrolled HIV positive mothers should receive ARV prophylaxis as well as EID according to national standards.

Various strategies are currently implemented to improve the performance of the program. Included but not limited to are: the specific assignments of community health workers to enrolled pregnant women to improve compliance with care and treatment and perform home visits, the rigorous planning of delivery and tracking of delivery dates for each enrolled pregnant woman, the establishment of post test clubs for enrolled pregnant women and the availability of transportation fees for the family,home visits , the availability of delivery kits with prophylaxis medicine for the mother and the newborn.

Various linkages will allow additional strengthening of the PMTCT program; PAM for food access and nutrition, CHAMP for referrals tracking and compliance, traditional birth attendants (matrones), community meetings aiming at men mobilization and involvement.

Education of providers on VCT best practices and the new guidelines for PMTCT will also be stressed during the next two years. Overall strengthening of prenatal care for better integration of PMTCT in reproductive health services will have to include the critical area of a suitable physical infrastructure for the general prenatal services at HUJ. This will help accommodate new demand creation as a result of community mobilization. Current established monitoring tools will be used to assess performance.

As per September 2011, 1,974 active patients were receiving HAART in the program. For the current fiscal year, the program will add 490 patients on HAART with the assistance of the Haiti Project/UMMSM and other partners of HUJ. The patients on HAART benefit from a well-established and rigorous service offering comprehensive, continuous, patient-centered and community-oriented care. The national guidelines are followed for the care of patients. The package of services delivered includes ARV provision in addition to the standard package of Care and Support .All patients on HAART have an "accompagnateur" and have met all the eligibility criteria established as per the program guidelines .

The program aims at providing ART to 100% of patients clinically eligible and is implementing appropriate strategies to this effect (tracking of all eligible but inactive patients, softening of psycho social criteria for HAART eligibility, assignement of temporary accompagnateurs ,intensification of home visits,appointment reminders,calling cards to the commumity health workers.

Retention of all patients (100%) on HAART is also an issue currently addressed through the following strategies: Strengthening through training activities the knowledge and skills of the "accompagnateurs," increasing of education and counseling for patients at risk of non-compliance, strengthening of the tracking system for patients with missed appointments maintains the activities of the support groups, increase access to laboratory services to optimize the patients biological monitoring.

These interventions will concur to the global strengthening of the Adherence Plan of the facility HIV care and treatment program.

Training and re-training of providers is an integral part of the program at HUJ. The Haiti Project of the UMMSM has emphasized HIV/AIDS training at this facility since the inception of the program. Training of providers is implemented in the medical services and at the Continuing Medical Education Center for HIV/AIDS, a joint initiative of HUJ and the Haiti Project. Mentoring, percepting and supervision are offered on a continuous basis to providers, including 3 HIV/AIDS nurses practitioners trained on a specific Haiti Project traning program.

Currently 100 children and adolescents are receiving HAART at Hôpital Universitaire Justinien (HUJ). The children receive HAART based on national guidelines and in the context of a family centered and community oriented care. The children and adolescent on HAART also benefit from the full package of pediatric care and support. "Accompagnateurs" is assigned to the family when parents have difficulties with adherence to care and treatment. Linkages with community organizations contribute in strengthening the care system for infected children and adolescents on HAART.

The Haiti Project has trained through a mini-fellowship in pediatric infectious diseases one of the attending physicians at the Family Practice Center. This physician currently supervises the care to HIV infected children at HUJ. Supervisory activities includes: Chart review, monitoring of immunizations in children, adherence to care and treatment. UMMSM will strengthen the linkages between pediatric and PMTCT services to ensure that all HIV exposed new borns with PCR positive are put on ART. UMMSM will integrate HIV care into outpatients and inpatient pediatric wards to boost pediatric ARV enrollement.