The purpose of the SIDALE program is to improve integrated HIV Clinical-based services by providing financial and technical assistance to a network of seven faith based hospitals and their satellite health centers (12) throughout Haiti. While the specific focus of the project is HIV/AIDS Care and Treatment, SIDALE will also improve the financial systems, management and leadership processes, strategic information capabilities, and business development strategies which will strengthen the health systems as a whole. The current network of hospitals included in SIDALE are the following facilities and their satellite centers: Hopital Espérance de Pilate, Hopital Sacré Coeur de Milot, Hopital Saint Jean de Limbé, Hopital Alma Mater de Gros Morne, Hopital Saint Boniface de Fond des Blancs, Clinique Bethel de Fond des Nègres and a seventh one to be identified under COP12. For FY12, SIDALE will continue to focus on identifying site capacity and performance gaps and rigorously address them through a capacity building feedback loop, applying targeted technical expertise and knowledge transfer to the clinical, managerial, financial, operations and M&E areas of greatest needs. SIDALEs support integrates the delivery of HIV clinical care and treatment services with primary care services. SIDALE will continuously work with this network of faith based hospital to strengthen and enhance their capacity to leverage resources from other donors to diversify their funding sources. As aforementioned the SIDALEs technical support in financial and management system will reinforce sites cost recovery system and increase local contribution in financing health activities. Through the partnership with Futures group, SIDALE will has implemented a robust monitoring and evaluation system.

Under COP12, SIDALE will continue to provide appropriate support to the seven institutions and 12 satellite clinics to offer high quality VCT services and also define strategies to scale-up VCT services. SIDALE will promote several approaches : 1) Institutional VCT: a/client initiated: friendly structure to facilitate people to come on their own to receive counseling and testing services; this strategy will increase the demand for HIV testing; and b/ provider-initiated: VCT services will be offered to all patients who come to the clinic, in all main units (general medicine, interne medicine, outpatients departments etc.); all the partner facilities will put an emphasis on TB clinics, antenatal and postnatal clinics to ensure that HIV screening is offered; 2) Mobile clinics in high prevalence areas will continue to be supported under COP12. SIDALE will ensure that each institution has enough well trained counselors, tools, materials and supplies to ensure good quality VCT services. In collaboration with MOH, SIDALE will conduct training and supervision for counselors in VCT to ensure valuable counseling and testing. SIDALE will support the implementation of the finger-prick testing strategy to shorten time, reduce loss to follow-up and increase the number of individuals being tested and receive their results the same day. On-site refresher trainings will be conducted and related follow-up will take place during technical assistance visits. IEC materials will be reviewed, improved and disseminated, to encourage testing in the general population and target groups. SIDALE will work with each institution to ensure that a strategy is in place between VCT services and HIV units to guaranty a good flow of HIV positive patients and help prevent loss to follow-up. SIDALE will continue to strengthen referral linkages with post-test clubs and care and treatment programs and will work with CHAMP and other appropriate community partners to conduct sensitization activities on the importance of testing and on issues such as HIV/AIDS stigma and discrimination and infection prevention methods. SIDALE will emphasize the importance of community mobilization to increase visits to the VCT centers, and to facilitate access to treatment, care and support of PLWHA. In addition, all clinical staff (regardless of their assigned department) will be trained on the fundamentals of HIV and TB infection. The prevention model will ensure high quality counseling and testing services for all patients, provision of a minimum package of prevention services including PwP and provision of high quality PMTCT services to decrease infections among newborns. SIDALE will also work with site management to ensure that the referral of all inpatients and outpatients to VCT services, and mandatory screening to identify co-infection among those who are HIV or TB positive, are components of the health system and protocols. SIDALE will ensure that all seven institutions are part of an external quality assurance program to ensure high quality testing performance. Finally, SIDALE will promote best practices and experience sharing in scaling-up VCT among the faith based institutions at least twice a year during partners meetings. SIDALE will provide counseling and testing to 44,000 people throughout seven faith based institutions by the end of September 2013.

SIDALEs goal is to help orphans and vulnerable children (OVC) grow and develop into healthy, well-adjusted and productive members of society. SIDALE will continue developing a mechanism for OVCs in the community that ensures that the children in need of HIV clinical services are referred to the care and treatment sites and that all OVCs within SIDALE are enrolled for services provided by community programs. SIDALE will organize training for community health workers and families, to ensure that they are informed about the special needs of infected children and OVC (i.e.: counseling on nutrition, education, health needs, etc.). The project will ensure that community workers and care givers are sensitized on stigmatization and linked to churches/NGOs/schools to collaborate and advocate on health and HIV issues. SIDALE will engage families, mother and fathers to assist in patient tracking within the community and ensure the follow up of care.

CMMB has been responsible in the past for OVC under the AIDSRelief Project and worked collaboratively with the communities in order to provide comprehensive services for OVCs, including care, treatment and psycho social support. This will continue with SIDALE through lessons learned and evidence-based best practices gathered under the AIDSRelief model.

Careful attention will be given in conceptualizing and implementing OVC activities to ensure that differing needs of boys and girls are identified and addressed, appropriate to their developmental stage. The girl child often faces a disproportionate level of risk and vulnerability for exploitation, physical and sexual abuse, trafficking, HIV infection and burdens of caring for family members. SIDALE in collaboration with CHAMP will address these risks and strive to relieve the excessive burden that caring for family members often places on children and youth. Strategies for addressing these issues may include interventions that ensure girls have all that is necessary to continue in school, including secondary or vocational level schooling. This may include ensuring the provision of funds for school fees, transport, books and/or uniforms, and that there is family/caretaker support for staying in school.

SIDALE will participate in all clusters working on building local, regional and national capacity to strengthen the structures and networks that support healthy child development, to gather and use strategic information, and to develop policy and program responses that lead to comprehensive and effective care for OVCs.

SIDALE will continue to provide technical support to sites to ensure that all TB patients are tested for HIV and all newly identified HIV positive patients are screened and tested for TB. SIDALE will ensure that the faith based institutions have well trained staff in TB case detection, TB treatment and TB screening. So far, AIDSRelief data showed that TB is poorly integrated with HIV/AIDS services at the sites level. During the FY2012 COP, SIDALE will continue to support the sites to better integrate the TB and HIV into primary care services. The project will provide the seven faith based institutions with mentoring and technical assistance to ensure that providers can treat both HIV and TB. SIDALE will promote TB program integration with HIV/AIDS programs at each site by establishing a strong referral system for an efficient flow of co-infected patients between the HIV and the TB units, with an emphasis on sharing information on the progress and outcomes of these patients between the units.

SIDALE will also continue working with Supply Chain Management Systems (SCMS) to ensure adequate symptomatic screening with PPD test and provision of related commodities, as well as INH for prophylaxis. SIDALE will continue to collaborate with the Ministry of Health (MOH) at the central and departmental levels, and other lead TB NGOs (International Child Care, CARE, and Groupe Haitian d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO)) to coordinate and monitor the national TB/HIV program.

SIDALE will improve safety and bio-medical prevention by working with sites to implement basic systems and protocols, facilitate appropriate waste management, increase bio-medical prevention and bring sites up to national and best practice standards. In particular, sites will implement systems to control the spread of hospital-based infections and to identify cases of facility-based drug resistance to TB (MDR-TB).

The project will also strengthen linkages with CHAMP to ensure early identification and case finding for TB and promote ongoing treatment support for patients. SIDALE will support the seven treatment facilities for intensified patient follow-up to improve treatment success and identify treatment failure for proper management.

SIDALEs core clinical team will provide the partner sites with appropriate on-site technical assistance and supervision to ensure that the sites regularly review and report high-quality data using the TB M&E framework.

SIDALE will implement a multi-pronged approach to providing comprehensive pediatric care and support that improves neonatal, infant and child survival in line with the national protocol of pediatric HIV management.

The approach includes: PMTCT, HIV testing and counseling for infants, children, and adolescents, comprehensive package of care of exposed infants and their HIV+ mothers including provision of cotrimoxazole (CTX) prophylaxis for exposed and infected children, Opportunistic Infections treatment, infant feeding and nutrition assessments, immunization, palliative care, psychosocial support services, and care for families.

The Polymerase Chain Reaction (PCR) initiative which is being used at all sites will be reinforced to ensure that early infant diagnosis is being fully utilized. Supporting the scale-up of child friendly spaces and services at hospitals to better serve pediatric patients and their families will also be considered. The approach aims to ensure that all HIV positive children are enrolled and benefit from a complete package of screening (opportunistic infections; including TB, Cryptococcus neoformans, PCP and CD4 count testing) and treatment.

SIDALE will continue to support laboratory services to perform all lab routine tests for the HIV/AIDS program. Laboratories will be properly staffed and equipped to ensure that all facilities have labs which meet the national standards of the ministry of health (MSPP). As such the project will ensure a) that all written Standard Operating Procedures and necessary tools to support good quality of services are available and b) the implementation of an electronic record system in collaboration with the National Laboratory.

Under the leadership of the Laboratory Advisor, SIDALE will continue to support continuous quality improvement at all sites. SIDALE will seek expertise from national and international partners to ensure Assurance/Quality Control protocols are implemented at all sites. Continuous technical assistance and supervision will be provided to ensure that the lab equipment remains functional, and training will be conducted to ensure that the lab technical skills of existing or new staff are accurate and up to date. SIDALE will liaise with the national counterparts (National Laboratory) to coordinate the maintenance and repair of all lab equipment.

To address the needs of sufficient space in some hospitals, extension and refitting have to be done to promote and enable safe TB processing and patient sample collection, as well as chemistry and hematology.

As identification of co-infected patients is important for quality of care and expansion of ARV services, where necessary, lab space will be reorganized to accommodate TB diagnosis capacity while implementing proper infection control measure as well as adequate management of contaminated biomedical waste.

SIDALE will support capacity strengthening activities in all areas of strategic information including: monitoring and evaluation, data demand and information use, and health informatics. Futures will implement central and site-level training and provide technical assistance to strengthen health facilities capacity to collect clean data and use it for decision making and for analyzing clinical and programmatic information in order to provide high quality HIV/AIDS care and treatment. This includes the capacity of the project staff in managing, analyzing and using clinical data not only to practice adaptive patient management but also to ensure sustainability and improved health facility planning and management.

The Site Capacity Assessment Tools (SCA) which has been used to assess the site during COP11 will be enhanced during COP12 to facilitate site adaptive management based on a SIDALE specific instance of the dashboard. IQTools, whose implementation started during COP11 and will be fully deployed and rolled out to all sites during the COP12. IQTools enables sites to automatically generate custom reports through query functionality, harmonize SIMPLE and iSanté data, and produce automated Quarterly reports, ARV pick-up report and cohort mortality reports, which can be stratified by population groups (male, female, and pediatrics).

Sites will receive technical assistance in data analyses techniques and patient line analysis, which will allow the analysis of several overall trends including TB incidence, provider diagnosis rates, and regimen completion by population groups (i.e. males, females, pediatrics). Sites will also receive support in the continued and increased analysis of retention and attrition data, as well as PMTCT and its linkages with child survival. mHealth, GIS and other mobile technologies will support tracking for Patient referrals and also a reminder system.

To support the strengthening of the network, using a multi-disciplinary approach, the SIDALE team will identify two or three sites that have already taken a leadership role in developing a culture of information. A CQI/DDIU specialist from these sites will be trained in EpiStats; and an IT specialist will receive capacity building in developing and maintaining databases, networks and other IT tools. These employees will be responsible for continuing to build capacity at their sites (better documentation, data analysis, and piloting new initiatives) and for assisting neighboring sites in developing their ability to manage data.

SIDALE will place emphasis on health systems strengthening toward sustainability by continuing the capacity building process launched under COP11. The project will continue to focus on identifying site capacity and performance gaps and rigorously addressing them through a capacity building feedback loop, applying targeted technical expertise and knowledge transfer to the clinical, managerial, financial, and M&E areas of greatest need. According to their individual needs, sites will be provided with training to improve supply chain management, leadership and governance, grants compliance and financial reporting, ensuring that appropriate policies and procedures are in place to support best practices. Appropriate IT systems will be put in place to ensure excellent management and use of information at all sites. The sites will also be supported to develop a diversified funding strategy by leveraging internal and external resources. Finally, SIDALE will work with sites to ensure engagement of local leadership, MSPP, UCP and other government structures, identifying areas for collaboration and utilizing the Community Services department (CSD) to pursue partnership of particular interest.

SIDALE will provide direct and concerted mentoring at all sites on all three core prevention areas (PMTCT, VCT and PwP) to ensure universal access targets are achieved in the course of the grant. The clinical team and their partners, in close collaboration with CHAMP, will continue to provide support on how to implement a successful minimum package of PwP at the site and community level. The minimum package of services for PwP consist of a) Assessment of sexual activity and risk reduction counseling, b) assessment of partner status, partner testing or referral for partner testing, c) Assessment of STI and if indicated STI treatment or referral for client and partner, d) assessment of family planning needs and if indicated referral for family planning services or safer pregnancy counseling, e)assessment of treatment adherence and if necessary support services for treatment adherence, f) assessment of need and referral of PLHIV into support group, post-test club, etc. SIDALE will work to implement at all sites the adapted PwP model developed by I-Tech in collaboration with the University of San Francisco California. SIDALE will support these activities in Milot, Pilate, Limbé, Gros-Morne, Fond des Blancs, Fond des Nègres and their surrounding areas. During the past years, Hôpital Alma Mater (HAM), with the Gerard Foundation support, has implemented a Cervical Cancer Screening (CCS) integrated into antenatal care using VIA (Visual Inspection of the cervix using Acetic Acid), and Cryotherapy is used to treat precancerous lesions. SIDALE, through COP12 funding, will strengthen CCS at HAM and advocate expanding these services to all sites, in partnership with Gerard Foundation. CCS will be included in the minimum package of care offered to all HIV pregnant women.

Under COP12, SIDALE will continue to provide appropriate support to the seven institutions and 12 satellite clinics to offer high quality VCT services and also define strategies to scale-up VCT services. SIDALE will promote several approaches : 1) Institutional VCT: a/client initiated: friendly structure to facilitate people to come on their own to receive counseling and testing services; this strategy will increase the demand for HIV testing; and b/ provider-initiated: VCT services will be offered to all patients who come to the clinic, in all main units (general medicine, interne medicine, outpatients departments etc.); all the partner facilities will put an emphasis on TB clinics, antenatal and postnatal clinics to ensure that HIV screening is offered; 2) Mobile clinics in high prevalence areas will continue to be supported under COP12. SIDALE will ensure that each institution has enough well trained counselors, tools, materials and supplies to ensure good quality VCT services. In collaboration with MOH, SIDALE will conduct training and supervision for counselors in VCT to ensure valuable counseling and testing. SIDALE will support the implementation of the finger-prick testing strategy to shorten time, reduce loss to follow-up and increase the number of individuals being tested and receive their results the same day. On-site refresher trainings will be conducted and related follow-up will take place during technical assistance visits. IEC materials will be reviewed, improved and disseminated, to encourage testing in the general population and target groups. SIDALE will work with each institution to ensure that a strategy is in place between VCT services and HIV units to guaranty a good flow of HIV positive patients and help prevent loss to follow-up. SIDALE will continue to strengthen referral linkages with post-test clubs and care and treatment programs and will work with CHAMP and other appropriate community partners to conduct sensitization activities on the importance of testing and on issues such as HIV/AIDS stigma and discrimination and infection prevention methods. SIDALE will emphasize the importance of community mobilization to increase visits to the VCT centers, and to facilitate access to treatment, care and support of PLWHA. In addition, all clinical staff (regardless of their assigned department) will be trained on the fundamentals of HIV and TB infection. The prevention model will ensure high quality counseling and testing services for all patients, provision of a minimum package of prevention services including PwP and provision of high quality PMTCT services to decrease infections among newborns. SIDALE will also work with site management to ensure that the referral of all inpatients and outpatients to VCT services, and mandatory screening to identify co-infection among those who are HIV or TB positive, are components of the health system and protocols. SIDALE will ensure that all seven institutions are part of an external quality assurance program to ensure high quality testing performance. Finally, SIDALE will promote best practices and experience sharing in scaling-up VCT among the faith based institutions at least twice a year during partners meetings. SIDALE will provide counseling and testing to 44,000 people throughout seven faith based institutions by the end of September 2013.

SIDALE will provide direct and concerted mentoring at all sites on all three core prevention areas (PMTCT, VCT and PwP) to ensure universal access targets are achieved in the course of the grant. The clinical team and their partners, in close collaboration with CHAMP, will continue to provide support on how to implement a successful minimum package of PwP at the site and community level. The minimum package of services for PwP consist of a) Assessment of sexual activity and risk reduction counseling, b) assessment of partner status, partner testing or referral for partner testing, c) Assessment of STI and if indicated STI treatment or referral for client and partner, d) assessment of family planning needs and if indicated referral for family planning services or safer pregnancy counseling, e)assessment of treatment adherence and if necessary support services for treatment adherence, f) assessment of need and referral of PLHIV into support group, post-test club, etc. SIDALE will work to implement at all sites the adapted PwP model developed by I-Tech in collaboration with the University of San Francisco California. SIDALE will support these activities in Milot, Pilate, Limbé, Gros-Morne, Fond des Blancs, Fond des Nègres and their surrounding areas. During the past years, Hôpital Alma Mater (HAM), with the Gerard Foundation support, has implemented a Cervical Cancer Screening (CCS) integrated into antenatal care using VIA (Visual Inspection of the cervix using Acetic Acid), and Cryotherapy is used to treat precancerous lesions. SIDALE, through COP12 funding, will strengthen CCS at HAM and advocate expanding these services to all sites, in partnership with Gerard Foundation. CCS will be included in the minimum package of care offered to all HIV pregnant women.

All sites and their satellites will continue to provide PMTCT services, in order to diagnose HIV/AIDS among pregnant women and reduce HIV/AIDS transmission from mother to child. SIDALE will continue to assist the sites in addressing major challenges related to preventing the transmission of HIV infection from mother to child. The strategy will put continued emphasis on comprehensive family-centered PMTCT services. All pregnant women will also be offered CT for syphilis, and treatment services if necessary. The main focus of the project will be to provide technical assistance and support to the sites to enable them to administer, in a timely manner and in accordance with the national guidelines, prophylaxis to at least 80% of HIV positive pregnant women who had prenatal care visits. In order to encourage good management of deliveries, SIDALE will ensure that the sites have adequate supplies for PMTCT in the antenatal care wards and will reinforce maternity services with appropriate equipment, staff and training.

In collaboration with CHAMP, the project will work to utilize community health workers and develop strong linkages with community opinion leaders and community based services to track pregnant women, provide on time prophylaxis to newborns, and improve PMTCT outcomes overall. Traditional Birth Attendants will also be used to track mothers and administer prophylaxis to those who do not intend to deliver in facility, while also continuing to increase number of pregnant women accessing prenatal care services and institutional delivery. Throughout the year, SIDALE will work to enhance quality of PMTCT services, by placing emphasis on improving service quality and integration through the case manager approach, and through strengthening the capacity of health systems ''as a whole''.

SIDALE will support the use of all National M&E Tools for PMTCT data collection, reporting and information. M-health Technologies will be used to ensure close follow up with the women for delivery purposes as well as to remind them of the need to keep in touch with the Health Center.

SIDALE will continue to support each site to scale up the enrollment of ARV clients through expanded hospital-based and targeted community-based VCT services that target patients at highest risk for HIV, and through referrals from clinical programs such as TB treatment programs. Training on ART will be provided to insure accurate knowledge among the clinical staff and updated information will be provided when necessary. Specific technical assistance and close site supervision will be provided to ensure that ART is initiated as soon as possible when feasible (the same day), while continuing adherence counseling. SIDALE will ensure that all patients newly enrolled under ART receive appropriate intensified adherence counseling on a regular basis and are provided with close follow-up to guaranty adherence success to ART. The sites will continue to monitor the patients visits to the clinic and to the pharmacy and implement timely follow ups.

SIDALE will promote strategies to expand ARV services at the sites, including 1) patients known to be adherent will be given 2-3 month ARV supplies to ensure that providers have enough time to see new patients who need frequent monitoring follow-up visits; 2) all HIV positive patients be screened for TB and the newly tested positive patients be enrolled on ART according to the national guidelines; 3) in order to increase the number of patients enrolled under ART, all seven sites will implement strong linkages with PMTCT services to ensure continuity of ARV treatment for HIV positive pregnant women enrolled in PMTCT. This strategy will also be applied to pansion of the ARV services to new sites.

SIDALE will seek to increase retention rates and reduce mortality rates through CQI/DDIU efforts and regular exchanges among partners on challenges and successes. The project will also work with the site management to ensure that referral of all inpatients and outpatients to CT and mandatory screening to identify co-infection among those who are HIV or TB positive is a component of the health system and their protocols.

Hospital laboratories will be scaled up to be capable of performing important routine lab tests to monitor ART and treatment outcomes. In addition, infrastructure will be enhanced to insure that SOPs are in place to ensure the quality of lab services. Sites will receive continued technical assistance in the implementation and troubleshooting of CBTS tools rolled out during the previous years. Technical assistance will also be provided to sites in streamlining community-based and facility-based services to ensure linkages are efficient and effective. The team will work to further reduce loss to follow up rates.

SIDALE will work to scale-up pediatric treatment and reinforce pediatric services to ensure the long term health of all HIV-infected children. At the site level, ongoing technical support will be provided in three key areas: determining eligibility; treatment initiation, monitoring and follow up; and practical pediatric treatment challenges. Sites will receive one-on-one mentoring to ensure quality pediatric treatment.

Efforts to identify children in need of treatment will continue by including children and siblings of patients, inpatients, children seen at child health clinics or well baby clinics, community vaccination campaigns, and orphanages, etc. in outreach activities. IEC materials will be created and improved to encourage pediatric testing and enrollment in care as well as to reduce stigma. SIDALE will support all seven partner facilities to better integrate HIV into primary pediatric care services in order to improve quality of services at Ped outpatient clinics. This strategy will increase attendance at the Ped outpatient clinics and will improve the capacity to identify HIV positive children.