The two main strategic objectives of theHaiti Institutional Strengthening Program (HISP) are: 1) Develop a center of excellence and teaching hospital for HIV clinical care and treatment that is supportive of the University of Notre Dame of Haiti (UNDH) post-graduate training program; 2) UNDH implements a high quality post-graduate training program.

UMB will provide direct support to UNDH, and the training network to build efficient health systems and institutional capacity to train health professionals in key specialtiesskills that increase Haitis capacity to sustainably support HIV/AIDS and TB programming. The geographic coverage of the program will be determined long term by the final placement of the trainees but immediate coverage will include Ouest, Nord, and Sud Departments. The target population is post-graduate physicians and nurses with an impact on the HIV/AIDS patients at the 5 training sites. To promote sustainability, the HISP will explore mechanisms for cost efficiency such as use of student fees to support the post-graduate training and the leveraging of private donations to UNDH in the later years of the grant. HISP aims to transition to leadership by the UNDH by the end of 5-year grant period. The creation and strengthening of the Grant Management Unit at UNDH will support in-house proposal development to effectively solicit additional funding sources such as the Government of Haiti and international donors.

Prior to PEPFAR, UMB developed a model for care and treatment support based on providing a comprehensive care delivery model that focuses on long-term treatment success by integrating community support through the JACQUES Initiative. This model was successfully adapted for the needs and settings of the AIDSRelief countries. The community based treatment and support teams developed under the AIDSRelief grant and will continue to use this effective model for providing HIV care and support to infected patients. A package of services will be provided that will include the use of treatment partners, home based care, prevention services, support groups, palliative care and psychosocial support, early diagnosis and treatment of OIs, safe water interventions, and linkages to support services such as reproductive health, food and nutrition support and income generating activities.

Reducing mortality through the early diagnosis and proper management of OIs was a focus area in the last years of the AIDSRelief grant. UMB will build upon the lessons learned and will provide advanced OI diagnosis to patients in care and treatment with the goal of reducing early mortality.

Retention in care has often been overlooked, with the emphasis falling on the retention of patients on ART. UMB will closely monitor the retention in care since it is a gateway to treatment and can be used as a springboard for promoting ARV adherence. The facility clinicians, counselors and DRO will be trained on how to generate and use weekly reports regarding missed appointments and CD4 count schedules so they can more easily track and monitor patients and assist them with staying in care.

UMB will collaborate with HIVQual, I-TEC, Futures Group and other partners of CDC and MSPP in their efforts to strengthen the systems in place to evaluate program results.

The School of Medicine and School of Nursing have faculty experts who will provide training to the two sites on palliative care and psychosocial support for both persons infected and affected by HIV. These services will be part of the standard package of care and will include approaches to address pain management and end of life care.

TB is an area of focus for the University of Maryland and the clinicians at Foyer St. Camille and the other four training hospitals will receive advanced training in screening, diagnosis and appropriate treatment for TB in the HIV infected individual. A TB screening tool will be implemented at each of the sites to ensure that all patients are screening for signs and symptoms of TB at each clinic visit. Linkages with the TB clinics will also be strengthened to ensure that all TB patients are getting tested for HIV and all HIV patients are screened for TB each time they come to the clinic.

Home based care teams will be trained and utilized to provide screening and referral of suspected cases. Hougans, or traditional healers, will also be trained on how to identify and refer potential TB cases and conduct contact tracing and testing for known TB cases. This approach was in the early stages during COP11 and based on the successes, this will be rolled out at the training facilities.

GeneXpert and digital x-ray technology will be available to the two facilities and these testing services will be utilized when clinically indicated and in accordance with National Laboratory standards and protocols. Referral testing may be set up for other hospitals in the network based on collaboration with MSPP and the National Laboratory. UMB will link with GHESKIO and PIH to coordinate their approaches to MDR TB identification and management to ensure a streamlined approach to monitoring and treatment. The laboratory staff and clinicians at the sites will benefit from the UNDH post-graduate training program activities also funded under this mechanism and these trainings will be leveraged to improve the quality of care provided at the training hospitals.

Monitoring of these activities will be done through the iSante, MESI and other EMR systems as approved by the MSPP. The TB and HIV monitoring tools will be used as the basis for all data collection and evaluation. In addition to these tools, UMB will work with the Comite du Qualite at each site to design TB/HIV specific evaluations and monitor the interventions for effectiveness.

UMB will work with CDC, GHESKIO, MSPP and LNSP to improve the management of MDR TB cases at the training sites and support designated sites to develop the clinical capacity to manage and treat MDR TB cases after they have been stabilized through the first round of treatment. Outpatient DOT capacity will also be increased at the training sites to ensure a comprehensive network of peripheral sites with the capacity to increase TB treatment completion and success.

Scaling up of pediatric care and support activities will be done at Foyer St. Camille. The services offered for pediatric patients will, where possible, be integrated into the rest of the care & treatment services to provide for a more family centered approach. Clinicians will receive training on pediatric ART formulations and proper management of pediatric cases since this has been identified as a weakness during the previous years of implementation through AIDSRelief.

Integration of pediatric services with maternal health and childhood immunization services will be done at the Foyer St. Camille and the training hospitals. The same package of services described under adult care and support will be provided for the pediatric patients. Linkages to OVC programs and organizations providing direct support will be done at the clinic level with a bi-directional referral system that can be tracked to monitor effectiveness.

Adolescents infected with HIV will be specifically addressed during the FY12 COP. With the increased number of pediatric patients reaching adolescence and a number of adolescent new infections, there is a need to have specific prevention approaches that are tailored to the needs of this population. Counseling regarding disclosure, adherence and issues of sexuality will be modified to address their needs and perspective. Youth support groups that were very successful in the previous years will be continued in COP12.

Pediatric testing will be implemented fully according to the national guidelines and VL testing will be available to all exposed infants. This testing will be supported for Foyer St. Camille and will also be done through linkages with other partners as necessary.

Lab and 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 UMB attributed program management, staff time and operational costs to these areas and is reflected in the budget code allocations.

Lab and 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 UMB attributed program management, staff time and operational costs to these areas and is reflected in the budget code allocations.

Despite significant success towards universal access, Haiti continues to be burdened by a weak health system, extreme poverty, disproportionate infectious disease burden and stigma related to HIV. Haiti has critically low density of human resources for health underscoring the need for trained infectious disease health professionals. Haitis educational institutions are under-resourced in materials, qualified faculty and space, and the quality and content of education, especially clinical instruction, varies greatly. Instruction in HIV and other infectious diseases, chronic diseases, and maternal and child health care depends upon the experience of the faculty member, and can be limited since specialization in these crucial areas is unavailable within Haitis academic and practice structure.

To address these gaps in health delivery services and clinical human resources with the capacity to provide quality care, UMB in collaboration with UNDH will implement a post-graduate training program for physicians and nurses. Trainees will participate in advanced clinical training in HIV/AIDS management, TB diagnosis, treatment and MDR/XDR TB management, maternal and child health.

To address the MSPP priorities the following four basic and advanced certificate programs will be provided for nurses: 1) Basic HIV/Infectious Diseases; 2) Basic Maternal/Child (includes focus on womens health & <5 mortality); 3) Basic Nutrition and chronic diseases (focus on hypertension & diabetes); 4) Advanced: Advanced Practitioner in Chronic Diseases (including HIV & TB).

The UMB UNDH collaboration will directly support institutional capacity building and address the shortage of human resources for health. To achieve the goal of institutional strengthening, the Grant Management Unit established at UNDH will be developed to manage the current USG funds and explore opportunities to diversify the funding base for UNDH through other donor sources and activities. The post-graduate training activities will ultimately improve institutional capacity and health delivery services both at the five training sites but also at the larger Haiti health network as the trainees graduate and enter facilities in Haiti to practice.

At the institutional level, capacity for monitoring of HIV/AIDS patient and program level outcomes will be increased. The sites will receive technical assistance to improve their capacity to conduct program and patient level evaluations of quality of care. They will also have the capacity to utilize this information to construct interventions and evaluate their relative success or failure. Post-graduate trainees will learn how to conduct basic data interpretation, critically analyze peer-reviewed research, and translate this information into clinical setting applications.

UMB will provide training on injection safety, post-exposure prophylaxis, blood borne pathogen protocols and proper waste management. The objectives are to have clear, posted standard protocols regarding injection safety, waste management and proper procedures for post-exposure prophylaxis in all areas of the hospital. Each nurse, doctor and laboratory scientist who interacts with blood borne pathogens will be provided on-site training with follow up mentorship on a quarterly basis.

Monitoring and evaluation of this program area will be based on set criteria relating to the physical presence of single-use syringes, lances and blood drawing equipment, sharps disposal boxes, gloves and other relevant materials as well as period monitoring of the actual practices for blood collection, injections, and invasive procedures. The UMB School of Medicine and the School of Nursing will draw on the standard protocols used by the university hospital facility as well the best practices observed in the developing countries in which they have worked.

A third component of the program will address the commodity management in the facility to ensure that adequate stocks of injection supplies and safety materials such as gloves are always available. Injection safety champions will be identified within the existing staff teams and this person will be responsible for routine checks of stock and documentation through a checklist system.

Prevention activities emphasizing abstinence and be faithful approaches will be supported at Foyer St. Camille. In the clinic setting as well as through support groups and community linkages, services relating to abstinence promotion will be provided. UMB will work with existing partners to promote proven interventions in the youth support group setting. Facility nurses and counselors will be trained on proper behavior change messaging and will provide promotional material to all VCT clients. These activities will be conducted in collaboration with the HVOP program area.

UMB will support HIV testing and counseling through both provider initiated and client initiated approaches. This will be done primarily at the health facility setting but will also be provided in the community setting where it is deemed that the yield of new cases identified warrants the effort required to provide these services in the community setting. There will be an emphasis on ensuring that each HIV positive person identified through the community and facility based testing is tracked directly into care at the facility or referred with proper documentation to a more convenient treatment center.

Provider initiated testing and counseling will be promoted throughout the hospital facility at each point of entry into care. UMB will work towards the PEPFAR Haiti wide objective of at least 30% of outpatients receiving C&T services. Training will be provided to a minimum of one nurse/counselor in each ward to ensure that 24 hour access to testing and counseling services are available. These individuals will also be oriented on how to properly link the patient into care and other services. Enrollment at the point of care will be piloted at FSC. While all patients will be offered testing, specific emphasis will be on the target populations of women through the outpatient department and the antenatal clinic, TB patients, and children. Approximately 80% of the funds will be used for testing in the PMTCT and TB settings.

HIV Counseling and testing (HCT) will be provided at HCT sites within the facilities and through community testing days in collaboration with the facility. The community testing days will be targeted to high risk populations and with a clear plan for how to effectively link infected persons directly into care. Clients coming to these HCT venues will be provided a package of services that includes abstinence, be faithful, condom use, and circumcision messaging. Counselors will be trained on couples counseling with a specific emphasis and protocol on interventions for discordant couples. Most at risk populations will be targeted based on the assessments conducted during the second half of COP11.

Discordant couples identified through the counseling and testing services and support groups offered at the facility will be enrolled into special programs that will provide targeted prevention services in addition to treatment for the infected partner. In the general clinic setting, the Adherence Red Flag Indicator questionnaire will be utilized to identify patients on treatment who may need additional prevention interventions. As this is a new program area in Haiti for UMB, additional activities may be planned once the composition and prevalence of most at risk populations are identified in the catchment area of Foyer St. Camille. This assessment will be conducted during the second half of COP12. Specific interventions will then be selected based on the composition of the most at risk populations.

In support of the goal of eliminating mother to child transmission, the University of Maryland Baltimore (UMB) will establish standards at the training hospitals and specifically Foyer St. Camille to demonstrate the best practices in prevention of mother to child transmission. The successes and lessons learned from the previous AIDSRelief activities will be built upon to focus on interventions that work such as mother-baby pair tracking, point of care enrollment and ART provision, the use of case managers, and improved delivery services at the facility. These interventions and approaches will be integral to the on-site education of the UNDH post-graduate trainees and will indirectly support the scaling up of PMTCT programs country wide as the trainees graduate and are placed at health facilities throughout the country.

The proposed targets for COP12 will be re-assessed as Foyer St. Camille (FSC) expands services. Progress at Foyer St. Camille (FSC) will be assessed on a monthly basis to ensure that the proposed interventions are being implemented successfully. The process of continuous quality improvement will be used to evaluate both the progress towards the targets and the quality of care that is being provided. Case managers will be empowered to conduct this continuous evaluation and review process at the site level and will be trained on basic data interpretation.

Community linkages and promotion of partner/family testing and disclosure will be promoted at the site level and UMB will work with other implementing partners in the Ouest department to ensure that comprehensive services are readily available at the point of entry for infected mothers. Couple and family support groups that were shown to have high uptake at the AIDSRelief supported sites will continue at FSC.

UMB and UNDH through the post-graduate training program will provide training in the advanced management of HIV, TB and other OI. Both pre-service and in-service training will be provided and is further described under the OHSS budget code narrative. On-site training, supervision and mentorship will be provided to the physicians and nurses by UMB staff and faculty at the facility level. Supervision and mentorship will occur at a minimum, on a monthly basis. Trainings will be provided semi-annually or more frequently if there is staff turnover.

Patient level clinical outcomes will be monitored on a regular basis at both the facility and program level. UMB jointly developed a questionnaire that identifies Adherence Red Flag Indicators. This form and approach has been piloted in several of the AIDSRelief countries and was shown to be an effective tool for identifying patients who may be at risk of treatment failure. In the absence of access to regular viral load testing, this is a critical tool that can be used by clinicians to identify patients who need more close follow up and be referred for resistance testing and subsequent second line therapy if warranted. The goal of the Adherence Red Flag Indicators is to identify patients before they actually fail treatment so that appropriate interventions can be provided that can help them get back on track with their treatment. This tool, in conjunction with the nationally approved EMR and quality improvement tools, will be utilized at the two sites to improve patient adherence and long term outcomes.

Retention of patients on ART will also include the use of the home based care teams to conduct home visits and ensure that patients come for their scheduled appointments. The use of accompangateurs will continue and they will be sensitized and trained on the best practices.

Missed appointment, CD4 count and loss to follow up reports will be utilized by the home based care and facility teams to better monitor patient performance. These reports will also be used to monitor program performance and assist the facility teams in rapidly identifying problems and developing effective interventions to address the issues. This will be done in collaboration with the Continuous Quality Improvement teams.

The laboratory for FSC will be equipped with the infrastructure, experts and clinical services of a specialty center in HIV medicine, including a reference lab for advanced HIV and ID diagnosis and training capacity in these areas. The training network will possess corresponding strength in infrastructure, staff, management, services and training capacity. The FSC site will be the core of the network and act as a reference hospital for diagnostic, clinical and training needs.

The following strategic principles will be applied to the training laboratory over the five year grant period: 1) Advanced HIV and ID Diagnostics lab, including scale up of laboratory infrastructure to support specific technologies, platforms and assays to increase diagnostic capacity for HIV specific testing; 2) Laboratory training for physicians and nurses in post-graduate training programs; 3) Reference center for HIV specific testing in Port-au-Prince; 4) Training center for lab technicians in the training network; 5) Achieves national and international accreditation; 6) Development of training network laboratories to support the post-graduate training program.

Often clinicians are less comfortable treating pediatric patients than adult patients. UMB will provide training, on-site mentoring and supervision to the clinicians at Foyer St. Camille to ensure that both nurses and clinicians are comfortable with providing pediatric care and treatment. This will include the provision of pediatric treatment job aids that will be readily available to all clinicians.

Integrated clinic days will be promoted so as to allow mothers and infants to receive care and treatment along with other maternal and child health care services at the same point of care. This will help to minimize loss to follow up, promote adherence and uptake of immunization services. The joint tracking of mother-infant pairs will also be done.

Laboratory services for pediatric patients will be provided at both facilities and will be capable of providing CD4% and viral load monitoring of children both pre-ART and on ART.