The purpose of this Leader with Associates (LWA) award is to provide technical support and assure achievement of the USAID Central American Regional HIV/AIDS Program's objectives to expand and strengthen the response to HIV/AIDS in Central American countries. The Capacity Project will carry out activities in Belize, Costa Rica, El Salvador, Guatemala, and Panama and may also, in the future, conduct some activities in Nicaragua.

The Capacity Project will work towards achieving the following results to contribute to the five-year Central America HIV/AIDS Partnership Framework: a) Best practices for a comprehensive care delivery system appropriate to locally available resources developed and applied; b) A comprehensive HIV/AIDS training and mentorship program for health professionals developed and implemented; and c) Tertiary and secondary treatment programs integrated with community-based support networks.

The strategic approach includes five interwoven technical strategies to improve the performance of health care workers and increase access to high quality care for PLWHA:

1. Improve human resources for health (HRH) performance by applying accepted performance standards, systematizing and institutionalizing the Performance Improvement (PI) strategy, and ensuring supportive supervision at secondary and tertiary level facilities;

2. Build HRH capacity at both the pre-service and in-service levels through revisions and updates of curricular content and teaching methods at university health and social welfare schools and standardization of in-service curricula and methodology for performance-based training;

3. Monitor care and treatment services by establishing a performance information system and using data for decision making;

4. Integrate care and treatment with community-based support to ensure complementary services and promotion of HIV prevention through facility-community partnerships especially with vulnerable groupsand establishing strong referral networks; and

5. Support innovation at the health facility and community level through use of information communications technology, such as m-learning, which uses mobile phone technology, and appropriate training information systems;

Additionally, the project will address cross-cutting themes by incorporating gender equity as well as stigma and discrimination reduction across all five technical strategies.

Gender roles and norms, economic dependency, violence against women or the feminine identity, and stigma and discrimination are drivers of the epidemic regardless of the mode of transmission. Understanding and addressing the issues of gender, stigma, and discrimination and their inter-relation with HIV/AIDS is crucial to reducing the spread of HIV infection. IntraHealth will promote the integration of gender-disaggregated data and the need to build host country counterparts' capacity for addressing gender, stigma, and discrimination dimensions in service delivery; and they will adapt tools to identify and quickly address gaps in these areas as well as raise awareness of the interrelationship between HIV and gender as well as stigma and discrimination.

To address gender inequities in HIV/AIDS, IntraHealth will promote the following

actions:

a. Incorporate a gender perspective in all pre-service education and in-service training and train instructors, preceptors, and trainers;

b. Integrate gender analyses within the Performance Improvement (PI) strategy and use results to improve programming at facility and community levels and ensure equity of service provision;

c. Disseminate information and results of studies on gender and HIV to public, private, NGO, and community-based health and social care workers;

d. Increase participation of women and other vulnerable groups (MSM, PLWHA) in community-facility partnerships to define HIV/AIDS priorities, implement solutions, and demand client satisfaction and accountability of health service provision;

e. Provide linkages to economic, legal, and psychosocial resources as a part of care and support services, active outreach and education to attract women, MSM, and sex workers to services, and organize PLWHA to become active in community services to help reduce stigma and discrimination; and

f. Incorporate a 'men as partners' approach in community-based activities such as community health fairs and prevention opportunities in order to help men define masculinity and strength as acting responsibly to prevent HIV infection.

To prevent stigma and discrimination related to HIV/AIDS, IntraHealth will:

a. Increase visibility and accessibility of HIV/AIDS services so they eventually become part of an essential health service package with HIV testing considered routine;

b. Assure strict confidentiality for testing, care, and treatment services to further efforts in stigma and discrimination prevention;

c. Involve PLWHA in the HIV/AIDS response through participation in community- facility partnerships, performance improvement assessments, and review of relevant training curricula;

d. Include stigma and discrimination prevention as an important content area in pre-service and in-service training curricula; and

e. Provide public, private, and civil society sector providers with knowledge and skills to prevent stigma and discrimination related to HIV/AIDS and vulnerable groups.

The overarching framework for IntraHealth's technical support will revolve around systematization and institutionalization of the project strategies for increased ability of the MOH/SSI to sustain the quality and performance improvement approaches. IntraHealth will contribute to sustainability by increasing commitment and ownership of the host country counterparts, joint development of projects, encouraging collaborative partnerships, and close and coordinated accompaniment and coaching.

The project will integrate treatment and care with community-based support. The major actions of the community-facility partnership strategy include:

Establishment of an integrated team or working group, consisting of key hospital staff, PLWHA leaders, and representatives from the community groups, which will guide efforts to form a strong hospital-community link and further ensure sustainability of the strategy;

Joint plan with proposed activities to help integrate treatment and care as well as ensure that clinic services, home care, and self-support groups complement each other and promote prevention opportunities as part of the care and support delivery;

Mapping of the community support network (including private providers). IntraHealth will help local stakeholders to inventory the community resources and referrals available to their clients and begin to build linkages between the facility and community. The mapping will also include a rapid assessment to determine needed technical assistance for HIV-related institutional capacity building;

Where the identified needs are within the mandate of the project, IntraHealth will assist with HIV institutional capacity building. Examples of this support include training in relevant HIV/AIDS-related services, linkages to MOH and private health facilities and other community organizations through the community-facility partnership strategy, development and participation in the referral and counter-referral network in their geographical area, assessment of performance standards and assistance in improving performance gaps, and provision of technical, reference, and other training materials; and

Holding at least two meetings ("encuentros") per year to present performance assessment results and changes/improvements undertaken, discuss progress on strengthening the community-hospital linkages through the earlier identified plan, problem-solving, sharing of client perspectives, and other relevant issues.

Other illustrative examples of coordinated activities in the community-facility partnership plans may include:

Participation of hospital staff, PLWHA associations, and/or community groups in local radio programs to promote prevention, gender equity, reduction of stigma and discrimination, and awareness-raising around care, treatment, and support services at the hospital and within the community network as well as changes made to improve HIV services at the hospital;

IntraHealth can use media outlets to sensitize media professionals and listening audiences to the importance of gender and sexual equality and how inequalities fuel the HIV/AIDS epidemic;

Participation in already scheduled town, community, or organization fairs to include prevention activities, awareness raising regarding services, HIV counseling and testing, gender equity, and stigma and discrimination reduction. IntraHealth will use these community forums to promote messages to involve men as partners and help men define masculinity and strength as acting responsibly to prevent HIV infection; and

Institutional capacity building to strengthen home care and other support services in the community through participation in relevant training activities provided by IntraHealth or via linkages to other collaborating partners working in home care, psycho-social support, income generating projects, and other support areas.

In relation to community facility partnerships, IntraHealth will examine the use of text messaging to link PLWHA and community-based groups to the hospital as well as share health information, send prevention messages, follow up with clients, provide text reminders for when it is time to take ARVs and/or other medications, or come for medical appointments. These messages could also notify members of the hospital-community integration team of upcoming meetings, progress on implementation of activities, and other relevant issues.

The project will promote VCT and early diagnosis among university student populations. IntraHealth will expand the training of university students and faculty in VCT to include nursing, psychology, social work, and other allied health schools in addition to medical schools.

IntraHealth will reach agreement with universities and their respective wellness centers to implement the VCT and early diagnosis strategy for the benefit of their student population. The strategy will consist of:

Training of faculty members to deliver the three-day VCT course to students from medical, nursing, psychology, social work, and other allied care schools to promote sustainability and institutionalization of the training. The wellness center staff will also be updated in VCT, gender, and HIV as well as stigma and discrimination reduction;

Selection and preparation of peer counselors, chosen from among the students trained in VCT, who show the most interest and commitment;

Rapid assessment of the wellness center's capacity to provide HIV/AIDS services, in particular VCT, and provision of technical support for any necessary updates or improvements. Wellness center staff will be updated on the referral pathway for further care and treatment services should a student test positive;

Strengthen the wellness center's health record system to ensure quality HIV-related data collection for monitoring of HIV services to students;

Advocacy by the university to raise student awareness about VCT services available at the wellness facility and the benefits of HIV prevention and early diagnosis;

Implementation of VCT services at the wellness center, carried out with support of the peer counselors; and

Hold periodic HIV testing days at the university in collaboration with the MOH/SSI. IntraHealth will negotiate with the MOH/SSI to confirm they will continue to support these efforts and ensure sufficient quantity of HIV test kits.

To ensure the best possible care, treatment, and support for PLWHA, it is critical that all community entities, including private clinics, provide services that comply with performance standards for HIV/AIDS service delivery including ensuring confidentiality to further reduce stigma and discrimination. For example, if a community-based organization provides nutrition counseling and services, they should know and apply the standards that relate to their work and have the necessary skills and additional inputs (supplies, job aids, etc.). IntraHealth will provide technical assistance to identified community organizations and private sector providers to ensure they have a copy of the performance standards, become familiar with them, and receive capacity building, updates, and conduct performance assessments.

In order to establish a training information system, IntraHealth will assist the MOH/SSI Training Department in each country to develop a database to capture all HIV/AIDS in service training, which will allow the institutions to track which health workers have been trained, in what topics, in what year, and from which health facilities. This will permit the MOH/SSI to identify unmet training needs, the individual staff due for skills and knowledge updates, where the capacity for different service components lie, as well as be more transparent in participant selection for workshops, courses, conferences, and scholarships. The training data will be disaggregated by gender to strengthen policy advocacy at national levels and district monitoring of gender equity in access to training and learning updates and events. As in all areas, IntraHealth will work in close collaboration with the MOH/SSI Training Departments and National AIDS Programs via a stakeholder leadership group to guide the design, development, and implementation of the training information system.

At the end of every performance assessment, an electronic spreadsheet in Excel format with the results detailing the level of compliance and the performance standards will be provided to each hospital. However, the spreadsheet does not allow for easy identification of the performance gaps in skills and knowledge, logistics and supplies, and staff motivation. This is something someone with much experience in performance improvement (PI) and data analysis can do with time and effort. However, for someone new to the process or who has never been involved, making programmatic or management decisions from the data would be challenging, especially on an inexpensive and routine basis. Therefore, IntraHealth will work with the relevant MOH/SSI stakeholders to:

a. Identify needs for the information system to monitor performance standards; and

b. Review current health information systems in each country to integrate the performance monitoring indicators into the country's existing information system.

The project will develop and carry out an implementation plan for strengthening the existing systems. To create an effective information system, IntraHealth will:

a. Establish a stakeholder leadership group (SLG) of relevant health authorities to guide the overall development and implementation process;

b. Review the current information systems used by the MOH/SSI to determine how to integrate the addition of the PI indicators into already existing health information systems;

c. Reach agreement in the SLG on the design of the performance standards monitoring component to integrate into the overall health information system;

d. Develop/field test the electronic performance monitoring component and install it in the hospitals;

e. Identify and train staff at each facility responsible for updating the system through data entry of subsequent performance assessment results;

f. Develop a dashboard tool to display longitudinal performance standards data so health workers, supervisors, and decision makers can monitor PI progress and highlight areas where greater or lesser input may be needed;

g. Train central and hospital level staff in data analysis, development of reports, and strategic use of the performance information dashboard for evidence-based management and programmatic decision-making;

h. Meet regularly with the SLG to update and analyze the data in the information system, engage in data dialogue opportunities, and ensure that the results are used strategically to address training, quality of care, management, and other decisions; and

i. Work closely with the SLG to design and develop the and institutionalize the regular use of performance standards monitoring component of the overall health information system within the hospitals to monitor care services and make appropriate management decisions.

The project will improve HIV/AIDS provider performance and integrate treatment and care with community-based support ensuring complementary and prevention promotion.

As part of the performance improvement (PI) strategy, the Capacity Project assisted doctors, nurses, auxiliary nurses, psychologists, social workers, nutritionists, and other allied health workers from 35 hospitals in Belize, Costa Rica, El Salvador, Guatemala, Nicaragua, and Panama are expected to make great strides in improving their own and the multidisciplinary team's performance in providing care and treatment to PLWHA through implementation of local changes to strengthen HIV/AIDS service delivery.

IntraHealth will facilitate and support the following activities, which encompass the PI process:

a. Conduct PI workshop to orient health authorities, managers, and health workers from newly included hospitals to the PI methodology, tools, and process prior to conducting the baseline performance assessment;

b. Assess compliance with performance standards using standardized tools, carried out by representatives from the HIV/AIDS Program, MOH/SSI central or regional level, and other hospitals while accompanied and coached by the IntraHealth country representative. The assessment is 2-3 days in length, depending on hospital size;

c. Present results to hospital authorities and staff and develop an action plan to reduce the identified gaps in performance;

d. Support implementation of the interventions in the hospital plan. In many cases the root cause for a performance gap relates to skills and knowledge. Training and learning interventions have included workshops on infection prevention and control, counseling techniques, and prevention of stigma and discrimination;

e. Facilitate intervention plan follow up meetings to monitor and motivate progress on implementation of identified interventions; and

f. Conduct subsequent performance assessments to see percentage change in compliance with standards and repeat the above steps.

In regards to training, IntraHealth will include individuals from the hospital and community support networkincluding private sector providersin relevant training workshops to build capacity and linkages with the formal health sector. Training PLWHA to assist in appropriate level of service delivery, such as peer support for HIV-positive clients, allows for task shifting and reduction of the workload of the hospital care providers. Examples of training include VCT, counseling on ART and TBDOTS compliance, home care, stigma and discrimination reduction, gender dimensions of HIV/AIDS, and prevention with positives (PwP).

In order to address referral and counter-referral networks, IntraHealth in conjunction with the MOH/SSI and HIV/AIDS Programs will work with the hospital community team to clearly define and promote an effective bidirectional referral system for HIV-positive clients to maximize integration and complementarity of services, ensure client satisfaction, and minimize client loss to follow up. Each local network will serve as a nucleus to inform community members of services offered at the hospital and community-based organizations, which include private care clinics. Each hospital, private clinic, and community organization working in HIV/AIDS will receive and post the list of support entities and services available.

The project will provide in-service training and updates to HIV/AIDS care providers from the public, private, and NGO sectors.

IntraHealth will build capacity of doctors, nurses, auxiliary nurses, social workers, nutritionists, and other allied health workers through appropriate training and learning support. IntraHealth strives to be cost effective, avoid duplication of efforts and resources, and maximize existing opportunities. IntraHealth will scan the training and learning environment to identify and inventory the existing regional and country specific educational and training opportunities in HIV/AIDS care and treatment, including TB co-infection, and associated behavioral and psycho-social aspects.

Based on a country's needs, IntraHealth will sponsor participation for HRH from the public, private, and NGO sectors to attend workshops, short courses, conferences, and diploma courses while ensuring equitable participation of women and men.

Depending on the quality and types of training workshops and courses available in each country, IntraHealth will also develop and facilitate in-service training for public, private, and NGO sector providers of HIV-related care and treatment. Illustrative examples of training include VCT, ART, TB-DOTS, PMTCT, infection prevention and control, stigma and discrimination reduction, and gender equity. Private health care providers represent a growing source of HIV/AIDS service delivery in Central America. As such, IntraHealth will make a conscious effort to include private and NGO sector HIV/AIDS care providers (many identified via community network mapping described before) in the available training workshops, distance courses, conferences, and other learning events.

The project will also have a focus on updating curricula in nursing, psychology, social work and medical schools. With a five year scope, IntraHealth will work to catalyze the inclusion of up-to-date HIV information and skills, including issues of gender, stigma and discrimination, through revision of the curricula of medical, nursing, psychology, social care, and other allied health schools of universities in the five countries. IntraHealth's pre-service strategy will include the close and coordinated involvement of the Deans/Directors of the selected health and social care schools and the university wellness centers (where students seek medical and psychological care) as well as relevant stakeholders from the MOH/SSI and HIV/AIDS Programs.

The HIV/AIDS curricular expert will analyze the content of teaching curriculum to assess the quality and type of information and skills given to students on HIV/AIDS and TB co-infection care and treatment, as well as prevention of stigma and discrimination, and make recommendations for updating them with state-of-the-art information and skills building.

Once the curricular analysis and recommendations are complete, IntraHealth will facilitate meetings with stakeholders to discuss the results and flesh out a plan to update the curricula and define the support needed. Illustrative areas of support will include:

a. Technical assistance for curricula modifications;

b. Facilitation of working group meetings to discuss and make curricula modifications;

c. Reference materials and access to experts and best practices;

d. Printing of final curricula; and

e. Training workshops to update faculty members in new curricular content.

Development/use of information technology will be used for distance training, care and treatment conferences, information dissemination, and an information/training system. Training of the healthcare workforce should be targeted to address specific performance gaps as identified in the hospital performance assessments and via other means. Addressing these gaps can be achieved through a multitude of channels, including information and communications technologies (ICT). Effective use of these technologies can enhance efforts to strengthen the knowledge needed by the healthcare workforce at all levels.