The FOSREF/CDC/ PEPFAR project will continue to serve nationwide its key target populations: Youth all categories (both sexes), Sex Workers and clients, pregnant women, People Living with HIV/ AIDS and their families, OVC . The project will expand by implementing services to the Center Department, through 2 new clinic- centers, one for the Youth (in Hinche -the main city of the Centre Department), and one for Commercial Sex Workers and Sexual partners (in Belladere/ city on border with the Dominican Republic).

The goal of the project is to reduce the HIV prevalence in Haiti, and to increase access to HIV/ AIDS services to the Haitian population. The project will continue to deliver a complete package of HIV/AIDS prevention, care and treatment services throughout the country to the most vulneralble groups and high-risk groups. The specific objectives of the project are to: 1) reinforce and increase access to screening and treatment of Sexually Transmitted Infections (STI) and HIV screening for 90% of all vulnerable and high-risk groups including migrants, within a comprehensive package of integrated preven-tion services, in a five-year period. 2) reinforce and increase access to care and treatment of HIV/AIDS, and support services to 100% of HIV (+) vulnerable and high-risk populations, within the FOSREF network, in a five-year period. In order to become more cost efficient, for all the components of the project (All program- areas) the emphasis will be realized on the complete integration of the Community Mobilization/ participation strategy and the clinical/ medical services strategy (institutional services). FOSREF will monitor the activities with ongoing data collection at institutional level and at community level, with community participation.

FOSREF will continue to reinforce its care and support services to PLHIV adult population in its adult centers located in the West department (CEGYPEF and satelites centers of Solino and Christ Roi). This program will continue to address the needs of the youth and CSW HIV Positive tested at FOSREF centers and those from all PLHIV FOSREFs partner- associations. The proposed program will allow FOSREF to provide standard palliative care in a network of 20 FOSREF centers particularly to the youth HIV Positive and CSW HIV positive. Activity 1: Assessement of the clinical status of patients and to provide opportunistic infection (OI) treatment and prophylaxis, nutritional assessments, counseling and support. Patients will also benefit from long-term follow-up to determine the optimal time to begin ART and to refer them to ARV sites. Other activities: kit distribution (nutrional and hygiene), and support group in all centers and communities integrated in the project. Activity 2: References and counter-references with the ARV sites located in the targeted departments for the PLHIV eligible for ARV. Other services: tracking, adherence support, psycho-social and preventive care services, and basic home-based care for the ARV patients. Activity 3: Post-test clubs and support groups for PLVIH, who will be trained as peers that have a key role in the screening of HIV (+) people presenting early signs or symptoms of opportunistic infections. Physicians, nurses, counselors, psychologists, social workers and health community workers are all part of the team in charge of activities. Home/community-based activities for HIV-infected adults and their families will be also a very important aspect of the program. The program will deliver Clinical to PLHIV with a complete package of prevention including: partner/couples HIV testing and counseling, risk reduction counseling, adherence counseling and support, STI diagnosis and treatment, family planning counseling, and condom provision (positive prevention) treatment of OI and other HIV/AIDS-related complications; The program will also provide to the PLHIV nutritional assessment, and psychological support. The program will make a strong emphasis on the pateint retention in care and support, particularly through its very well organized of Community system of follow up of the patients and the well organized system of referrals, with accompagnateurs. The 6 exisiting Palliative care centers of FOSREF in the West department in the commune of Port au prince and Delmas will have their laboratory settings well reinforced and the other 14 centers in the West deparmtment will, progressively have also a reinforcement of the laboratories. It is important to signalize that there will be very strong linkages between those centers delivering HIV care and support with the ARV center of FOSREF (CEGYPEF), and the referrals and contre-referrals will be well organized. The staff of the centers will regularly evaluate the performance of the program, in order to take measures to correct any weaknesses. This will be realized with the support of the Chief of Care and Service of FOSREF, the staff of the section of Quality of Services at Central level, and the HIVQual Committee at center level. All these activities and interventions will permit to have a better adherence of the patients and will permit to have the retention of the patients and avoiding abandon of patients under treatment.

The FOSREF OVC project is to improve the social conditions, health and quality of life of OVC and provide support to families caring for OVC in Haiti. This is in line with the national PEPFAR OVC goals which prioritize a family-strengthening approach. The activities will continue to be carried out in five departments within Haiti: South, South East, Grande Anse, Nippes and West by FOSREF, a national non-governmental organization. The project will target children of both sexes, less than 18 years old, who are infected with HIV, or who have lost one or both parents to HIV/AIDS or who are directly affected by HIV/AIDS. Most children will come directly from linkages to the FOSREF Palliative Care, PMTCT and ARV programs, thereby further reinforcing our internal referral system.

To achieve its goal, this program will put special emphasis on key issues related to OVC and will have a strong community-level focus. The Clinical services delivery strategy which is a key strategy of the project will allow OVC to have access to a large range of clinical / psychological support services and community outreach services for OVC and supported families. Activity 1: Training sessions for OVC peers will be organized at the center level in the five departments served. Activity 2: Provision of psychosocial (psychosocial support to OVC at center and community level and for individual families) and educational support (school fees, school materials and uniforms) and vocational training for older OVC. Activity 3: Specific individual or group education sessions will be organized for OVC girls on self-esteem, negotiation skills, and life-skills. Activity 4: Clinical services for OVC with basic clinical care for common diseases such as non-complicated respiratory infections, diarrhea. Referrals of OVC presenting complicated diseases, at community and at institutional level. Activity 5: Economic strengthening of OVC and families, with income-generating especially for the poorest and most affected large families. The OVC team is comprised of physicians, nurses, psychologists, counselors, social workers and OVC peers.

In past years, the program has had major successes in identifying and linking OVC to available services. This has been accomplished through the well-organized referral system between the Palliative care and PMTCT components of the program and the OVC program. On the other hand, the program has known some challenges. The first is the vulnerability of most children in Haiti, not just OVC; this has determined a higher than expected volume of demands for services from the community, which the program, as defined, could not respond to. Another challenge has been the stigmatization and discrimination towards OVC caused by the actual services provided to them; when OVC can take advantage of services that should be available to all children, especially vulnerable and extremely poor ones, discrimination happens. The project has been able to deal with this issue by organizing activities for all children (both OVC and non-OVC) while ensuring that the project includes specific interventions for OVC only (or primarily).

In order to build an evidence base for the strategies and activities used, program impact will be evaluated mid-term and at end of project. Success stories and best practices will be recorded at community and deparmental level.

From its 33 youth, general population and SW-specific centers, the projects network will grow by the second year through the expansion of its specialized VCT and STI services to MSM and migrants. Activities targeting men will continue to focus on specific sub-populations such as men with multiple partners, men with high-risk sexual behavior, clients of prostitutes, and single men, with special emphasis on gender equity. Activities for pregnant women will continue to be mainly delivered in the four adult sites located in the metropolitan area and sub-urban, marginalized areas, of the West Department; they will also be available to all the pregnant young girls in the youth centers at national level, with Family Planning services integrated to the HIV services.

FOSREF will continue to provide VCT services to CSW and clients in 11 CSW-specific sites. The CSW trained peers will continue to be fully involved in the counseling process as key actors. FOSREF will continue to promote VCT services at fixed points of prostitution including brothels and bars and conduct HIV awareness sessions for clients of CSW in an effort to discourage them from engaging in high-risk sexual behaviors. HIV(+) CSW will be integrated in support group activities promoting positive prevention and gender equity and enrolled in Palliative Care or ARV treatment, with case managers and social workers playing an essential role in tracking and follow-up, as well as establishing successful linkages, within our network.

FOSREF will continue to provide VCT services to youth in the existing 18 specialized youth centers.Trained youth facilitators will continue to serve as counselors. Youth aged 15 to 24 years will continue to receive VCT-related services, integrated with other reproductive health services. Both HIV(+) and HIV(-) youth will be integrated in post-test clubs. HIV(+) youth will be referred for care and support services as well as ART. A team comprised of physicians, nurses, psychologists, lab technicians, and youth facilitators will conduct the activities. This strategy will be extended to MSM, and Migrants for STI management and VCT.

The program will continue to counsel and test pregnant women for HIV during prenatal visits and will ensure that HIV(+) women are formally enrolled in a PMTCT site offering a comprehensive package of PMTCT services in their community.

In our network of CSW centers, the average HIV prevalence among the CSW is around 5.4% (with the highest rate in the Commune of St Marc/ Artibonite which is 10%, and the lowest rate in the west department (Commune of Petion Ville: HIV prevalence among CSW: 4%). For the youth the average prevalence in our national Youth/ VCT program is around 1.9 to 2.3%.

The FOSREF s VCT program has tested more than 23.000 people for the last year, and more than 60% of the services providers of the FOSREFs network have received refresher courses during the last year. It is important to signalize the in the FOSREFs VCT network program, all the VCT services are completely integrated with the other services of the centers (Psychological support, Family Planning, Post test clubs etc... etc&). People tested positive for HIV are automatically integrated in the Post test clubs activities/ support groups, and are enrolled in care and support program.

FOSREF will continue to deliver high-quality PMTCT services to pregnant women in all four of its adult centers located in Port-au-Prince (West department), and will extend them in COP12 to pregnant young girls in the youth centers, located in the West, North, North-East, North-West, Artibonite, South, South-East, Nippes and Grande-Anse departments.

This extension of services to pregnant youth will allow FOSREF to raise its annual targets from 600 (for COP11) to 825 and 975 respectively for the next two years.Those targets will be achieved through the integration of PMTCT services into the package of clinical services already offered at the youth centers and the promotion of services in the communities served by the youth and adult FOSREF centers.

Year-round community mobilization activities promoting VCT, prenatal care and PMTCT and special activities for specific occasions like Mothers Day, will be organized in order to increase PMTCT uptake. The project will continue to use the Clinical service delivery strategy with the Prenatal clinic as the key point of entry for pregnant women and youth. This will also allow for integration into psychosocial support services for women PLHIV, access to support for delivery and referrals for access to OVC services. All these strategies have proven to be effective in increasing retention and adherence and will continue to allow for adequate access to screening, treatment, care facilities and support services, within our network.

Individual information sessions will cover HIV C&T during pregnancy for all pregnant mothers, and also for all women in the waiting rooms of those SRH adult centers. Services provided will include information and education on HIV prevention, psychological and nutritional support, referral system for HIV(+) mothers and training.

The integrated PMTCT services will continue to be delivered in coordination with the other formal services (Palliative Care, VCT and Family Planning). For all pregnant women tested HIV positive, the case manager with the community workers will play a central role in the active search for all contacts (particularly sex partner/s), and family members will be informed about VCT. They will receive psychological assistance both at community and center level. All the HIV positive pregnant women will have regular medical exams, and will have basic lab exams such as: syphilis testing, all blood prenatal routine exams, urines, vaginal smears, CD4. There will be counseling sessions for pregnant women regarding PMTCT during prenatal visits; HIV positive women will be formally enrolled and received a comprehensive package of PMTCT services.

All the HIV positive pregnant women will receive bi-therapy during their prenatal visits. Under the supervision of the case manager, the accompaniers of the centers will ensure that all pregnant women receive their therapy also during the period of delivery, and in the postnatal period, since the 4 adult centers and the youth centers do not offer maternity/delivery services. A team comprised of physicians, nurses, counselors, case managers and community health workers are in charge of these activities. Progress will be periodically measured by ongoing collection of data, scheduled supervision and quality monitoring as well as reporting of the project activities.

TBD

The program will allow FOSREF to continue to provide ARV services to its patients in the West department in the FOSREF/PEPFAR- ARV center(CEGYPEF),, particularly the youth and CSW patients. This ARV center, which is the FOSREF main adult center , deserves all FOSREFs clients (Youth, CSWs, adults etc&) tested HIV(+), of all 18 FOSREF VCT sites in the Metropolitan area. All HIV(+) patients from those centers will continue to be referred to CEGYPEF determining improved programmatic efficiencies permitting continuous expansion of the ARV services.. The key strategy of the project for the ARV component is: the delivery of specialized ARV services to the patients at clinical level. The services will continue to be delivered by a well-trained team at center level. The ARV center will continue to have the complete collaboration and assistance of GHESKIO for complicated cases and particularly to manage any cases of resistance. It is important to signalize that the ARV services are incorporated into a complete comprehensive care and treatment package, including ART provision, clotrimoxazole prophylaxis, and TB screening, all these services available at CEGYPEF center. The project will reinforce the infrastructure of the CEGYPEF laboratory and of the 2 CEGYPEF satellites. All the clinical staff/ providers at CEGYPEF centers will receive refresher courses. It is important to signalize that under the responsibility of the Chief Medical center of CEGYPEF; there will be a strict supervision and control of the clinical monitoring of all patients receiving ARV. There will be also a strict supervision of all related laboratory activities. The clinical staff of CEGYPEF will have to assure that all patients are receiving the complete and high quality care for their opportunistic infections. This system will be reinforced by the community network (social workers, accompagnateurs / escort) that will have to assure the follow-up with the patients (home visits) and to address all their needs for referrals to the center for clinical services. This system will be supported with the Support groups activities that will be a key aspect in the continuum of care for the patients receiving ARV. The HIVQual committee of the center will play a key role in the follow-up of the patients and will be a key factor in the control of the quality of care that the patients are receiving. The staff will assure the adherence of the patients to the treatment, through the well organized system of continuum of care at institutional level and at community level (escort etc&). The staff of the center (CEGYPEF) will regularly evaluate the performance of the program, in order to take measures to correct any weaknesses. This will be realized with the support of the Chief of Care and Service of FOSREF, the staff of the section of  Quality of Services at Central level, and the HIVQual Committee at center level. All these activities and interventions will permit to have a better adherence of the patients and will permit to have the retention of the patients and avoiding abandon of patients under treatment. It is important to signalize that the project with its strong well organized community system escorting the patients and the complete integration of those patients in the Community/ support groups will guarantee the sustainability of the ART service delivery.