Integrated Activity: This activity is linked to Activity IDs 18985.08, 18973.08, 18957.08 and 5301.08.

NOTE: The activities described below are not new, but have been performed by International Child Care

(ICC) Grace Children's Hospital (GCH) under the umbrella of Management Sciences for Health. CDC Haiti

currently has a co-operative agreement with ICC for TB activities. In an effort to improve efficiency,

PEPFAR funds for GCH will be provided directly to ICC.

SUMMARY: Grace Children Hospital will strengthen the PMTCT component of its program to offer a

comprehensive package of prevention, care and treatment services for the population of the metropolitan

area, particularly those who reside in Delmas, in addition to being one of the main reference centers for

pediatric HIV/AIDS services. PMTCT services will be implemented using the same model, previously

described. Grace Children will complement GHESKIO's network for making services more accessible to the

important population that resides at the metropolitan area where most HIV/AIDS case will be detected and

enrolled into a comprehensive program.

BACKGROUND: For more than a decade, Grace Children's hospital has been the main reference center for

treatment of children affected by Tb. The institution is providing also a comprehensive package of primary

care services such as child immunization, ARI treatment, Reproductive Health. Grace Children's Hospital

will improve its PMTCT services with the availability of a new maternity ward. This will contribute to the

provision of full prophylaxis at all three stages of pregnancy. The primary targets of this intervention are the

2,000 pregnant women, which on average attend services at these facilities. At community level, health

agents of Grace Children's hospital will be seconded by those of World Concern/AERDO.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1. Support to 1 VCT/PMTCT site that will enable the provision of a full package of services

including: (i) Opt-out Counseling and testing to all pregnant women (ii) STI management using a syndromic

approach iii) Prophylaxis of opportunistic infections (OIs) (iv) Reproductive health services, including safe

obstetric practices and family planning counseling for HIV positive individuals and the promotion of

condoms; (v) Psychosocial support through individual and family counseling, mainly by social workers and

community health workers and through the setting up of support groups (vi) Case management of HIV

positive pregnant women including clinical and biological monitoring (vii) short-course ARV regimen for HIV-

positive women according to national guidelines (viii) education on best infant feeding practices.

Activity 2. The funding will support: (i) hiring of more qualified staff, (ii) hiring of dedicated social workers

and community health agents for PMTCT, (iii) acquisition of educational materials and support equipment to

facilitate educational activities (iv) support to some operational costs incurred by facilities

Activity 3: The creation of a retention package, which includes: (i) subsidies for the cost of follow-up visits

and hospital delivery (ii) maintenance of women support groups (iii)incentives to TBAs

Activity 4: Implementation of an integrated PMTCT (+) package model. This activity implies the

implementation of an integrated family-centered PMTCT (+) approach that will offer HIV/AIDS partner

referral services, couple counseling and pediatric care to women who test positive.

Targets - September 2009

- Number of service outlets providing the minimum package of PMTCT services according to Haitian and/or

international standards: 1

- Number of pregnant women who received HIV counseling and testing for PMTCT and received their test

results: 2,000

- Number of pregnant women provided with a complete course of antiretroviral prophylaxis in a PMTCT

setting: 50

- Number of health workers trained in the provision of PMTCT services according to national and

international standards: 5

SUMMARY: With Fiscal Year (FY) 2008 resources, ICC will provide, through Grace Children's Hospital,

comprehensive medical services, psychosocial support, and follow-up to 3000 HIV/AIDS patients living in

the metropolitan area by the end of September 2009. This program will be linked with the TB/HIV, ARV, CT,

and PMTCT services that Grace Children's Hospital is expanding. It will be also linked to other community-

based programs that are being offered through community based organizations (CBO) in the same

geographic area. The target populations include people living with HIV/AIDS and their families.

BACKGROUND: ICC has been a key player in the system of care in Haiti. They are well known for their

important role in supporting the TB program in Haiti throughout the country. Through Grace Children's

Hospital, an affiliated non-governmental organization (NGO) hospital, ICC has been providing specialized

TB care, integrated with primary and general care for both adult and children, with support from USAID and

the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Since the launch of the President's

Emergency Plan for AIDS Relief (PEPFAR), the United States Government (USG) has been providing

resources to ICC to integrate HIV in its network of TB sites. Resources were also given to support

integrated basic care and anti-retroviral (ARV) services at Grace Children's Hospital and to implement a

pilot model of HIV pediatric care. So far this program has been very successful in enrolling 1,000 patients in

care; 300 HIV positive pregnant women in PMTCT; 400 patients, including 100 children in treatment; and

150 HIV patients in TB treatment services. The USG believes these results will further increase with FY

2007 resources, while steps are being taken to improve the quality of the clinical based programs

nationwide through a better system of QA/QI.

In FY 2008 the USG will continue to provide resources through ICC to make Grace Children's hospital a

center of excellence for integrated TB/HIV, palliative care, and ARV services. For basic care, the focus will

be to provide clinical, psychological, nutrition, and laboratory assessment and follow up to 3000 patients to

prevent and treat opportunistic infection (OI) and malnutrition, and to monitor the optimal time for providing

highly active antiretroviral therapy (HAART). ICC will establish strong links with ARV and TB services

provided at Grace Children's Hospital to ensure continuum of care for those in need of HAART and TB care.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Through Grace Children's Hospital, all patients testing positive will be enrolled in clinical palliative

care. Thereafter, they will receive access to laboratory, clinical, nutrition, and psycho-social assessments,

and follow up services to prevent and treat opportunistic infections, malnutrition, and pain and symptom

management. Additionally, ICC will monitor the optimal time for providing HAART and create a supportive

environment for adherence to long term follow up and care. Funding will be used to staff each palliative

care site with a multi-disciplinary health care team, including physicians, nurses, psychologists, social

workers, counselors, nutritionists, community health workers, and laboratory technicians. Emphasis will be

put on training health nurses to play a key role in providing these services (see MSPP palliative care

narrative). Funding will support enhancements of infrastructure, equipment, materials, and supplies for

service organizations at clinics, laboratories, and pharmacies. ICC will conduct these activities in

conjunction with Supply Chain Management System which will provide laboratory reagents and

commodities and opportunistic infection drugs.

Activity 2: Human capacity building:

ICC will ensure that clinical and community staff at Grace Children's Hospital receives continuous training,

supervision, and QA/QI assistance to acquire and maintain necessary skills in HIV/AIDS care and

treatment. Emphasis will be put this year on training health professionals in nutrition assessment, follow up,

and recuperation to make sure that all sites are integrated with nutrition services. ICC will work with

GHESKIO, INSHAC, and MOH to achieve these goals (see aforementioned organization's narratives). To

sustain a workforce of the highest quality at Grace Children's, ICC will continue to support the technical

team for the TB/HIV program.

Activity 3: Social support services:

Special attention will be given to the need for social support for patients enrolled in the palliative care

program. Funding will allow Grace Children's Hospital to hire a social work team lead by a social worker that

will be in charge of assessing the social needs of all PLWHAs and provide them social support services.

Sites will provide direct support (e.g. fees for services such as delivery, hospitalization, x-ray) and for

transportation to appointments. Patients will also be referred to the PLWHA association and community

based organizations (CBO) in charge to offer community palliative care services in the metropolitan area. A

social worker will be added to the ICC team to provide program oversight.

Activity 4: Home based care

ICC will increase the number of community health workers at Grace Children Hospital to accommodate

scale-up of palliative care services. The community workers will be in charge of tracking patients (including

pregnant women enrolled in PMTCT and infected and exposed children), provide at home adherence

support, provide health education on best health and nutrition practices, counseling for positive behavior,

distribution of care and preventive commodities such as condoms, ORS, symptom and pain medications

according to the guidelines. Community workers will be trained in symptom recognition, and syndromic

treatment and rapid assessment of psychosocial problem of patient.

Activity 5: Psychological support

Funding will be used to make psychologists available at Grace Children's Hospital to provide support to

PLWHA to reduce denial, assist in psychological assessment and follow up, and to prepare for HAART if

needed. Funding will also be used to continue to support PLWHA support groups around each site to create

a supportive environment for treatment adherence and stigma reduction. In addition, local community

leaders, traditional healers, and religious leaders will be incorporated to encourage and enhance support of

patients within the community. ICC will work with other CBOs to continue to penetrate the religious sector in

an effort to bring HIV/AIDS and treatment awareness to the forefront in churches and religious groups and

to get them involved in providing spiritual care to patients.

TARGETS

Number of health professionals trained: 150

Number of patients enrolled in care: 7,000

INTEGRATED ACTIVITY FLAG: This activity is linked to Activity IDs 18985.08, 18973.08, 18957.08 and

17929.08.

SUMMARY: With additional resources, International Child Care (ICC) will continue to support the national

effort to strengthen and expand the Tuberculosis (TB)/ HIV program throughout the country. Building on the

successful implementation of the TB/Directly Observed Treatment Short-Course (DOTS) program and a

large network of HIV care and treatment services, ICC will focus on strengthening and expanding HIV

counseling and testing (CT) services as well as care and treatment services within its network of TB clinics

with no HIV services. ICC will focus on those clinics with high volumes of TB patients to ensure that all TB

patients enrolled in these clinics get access to HIV screening and care as needed. ICC will also support

implementation of a TB/HIV center of excellence at Grace Children's Hospital for training and quality

assurance/quality improvement (QA/QI). ICC will provide technical support to the MOH to develop national

norms, guidelines, and tools to build human capacity, improve monitoring (including drug resistance) for the

TB/HIV program and to implement TB infection control measures.

Background:

Over the last 30 years ICC has been a key partner of the Ministry of Health (MOH) in the fight against TB in

Haiti. Since 1995, ICC has played an important role in rolling out the TB/DOTS strategy adopted by the

MOH, and providing support to implement TB/DOTS services in five departments (North, South, South East,

West, and Central Plateau), and the overall management of the program in planning, training, monitoring,

supervision, and logistics. ICC is operating through an important network of hospitals, health centers, and

few stand alone TB clinics. One of them, Grace Children's Hospital located in the Port-au-Prince-

metropolitan area, specializes in providing TB care, particularly to children and provides such care to a large

number of patients in integration with other primary health care services. This hospital has the potential to

serve as a center of excellence for training and QA/QI.

Since 2005, the United States Government (USG) elected to build on ICC expertise and its network of TB

clinics to implement TB/HIV services. TB clinics located in the five other departments where ICC does not

have a presence have been supported through the two other lead TB non-governmental organizations

(NGOs), Cooperative for American Relief Everywhere (CARE) and the Centre Pour Le Développement et la

Santé (CDS). The main focus of ICC has been to integrate CT services as well as HIV basic care in the TB

clinics with no HIV services and to establish referrals with antiretroviral (ARV) services for co-infected

patients in need of highly active antiretroviral treatment (HAART). In TB clinics where HIV services have not

been integrated, ICC has made the effort to link them with HIIV sites in the same area to provide HIV

services to TB patients. This activity has been linked with other USG efforts to integrate, through care and

treatment HIV networks, CT services in TB wards located in facilities offering both HIV and TB services.

To date, through the ICC network, seven TB sites have been reinforced to provide HIV counseling, testing,

and basic care services. With Fiscal Year (FY) 2007 resources, the USG expects to expand this effort to 14

sites (including seven new). So far, through ICC, close to 2,000 TB patients (out of a total of about 12,000

detected and treated thru the ICC network this year) have access to HIV screening. Among them, close to

400 were HIV positive and enrolled in care while 200 have been treated with ARV. In addition, ICC, together

with the other lead TB NGOs, has played an important role in developing tools for TB/HIV monitoring. ICC

has also developed the capacity, through a mobile team, to perform supervision and QA/QI for TB/HIV.

With FY 2008 resources, the USG will continue to build on the ICC TB network to expand and reinforce

TB/HIV services. Due to the poor performance of CARE in integrating TB/HIV in its network, the USG has

requested ICC to expand its activities in CARE TB network sites in four departments (Grand'Anse,

Artibonite, Nippes and North West). The other 10th department (North East) will be supported thru Center

for Development and Health (CDS). Through ICC six additional TB sites will be targeted this year for

reinforcement and integration with CT and HIV basic care services. In addition, ICC will continue to build a

strong referrals system in each department between the other TB sites that do not have HIV services with

HIV sites located in their target areas. In addition, ICC will continue to play a major role in policy

development, human capacity building by providing hands on training, supervision and QA/QI for the

program through their mobile team that will be reinforced with trained health professionals in TB/HIV care.

ICC will also assist Grace Children's Hospital to become a TB/HIV center of excellence (COE) that will have

the logistic and human resources capacity to train health professionals in TB/HIV for the care and treatment

networks. This effort will add to the effort initiated at Sigueneau Hospital thru GHESKIO to make it also a

center of excellence for training.

Expected results: Through ICC, 10,000 TB patients (representing 66% of expected TB patients throughout

the nation) will obtain access to HIV screening services. We expect that 20% (2000) will be HIV positive and

will enroll in care while 5% (500) will enroll in ARV.

Activity 1: ICC will allocate resources to support service organizations at 20 TB clinics (including six new)

with the highest volume of TB patients throughout 9 department service area. ICC will use these resources

to hire at each site the range of human resources personnel (counselors, physicians, community and social

workers), reinforce infrastructure (including laboratory) to deliver counseling services and HIV palliative

care, including clinical and community follow up. ICC will also reinforce in coordination with the national lab

and Supply Chain Management System (SCMS) laboratory capacity at each site so that laboratory

personnel are able to perform CD4 testing to detect co-infected patients in need of ARV. These 20 TB sites

will be part of the palliative care network sites that will benefit support for opportunistic infections (OIs)

through SCMS -- (see SCMS narrative) and support social services through the community-based

organizations (CBOs) that are offering these services in the different departments.

Activity 2: ICC will establish linkages between the 20 targeted TB sites and the ARV sites in their catchment

area to ensure continuum of care for co-infected patients in need of HAART. ICC will also establish

referrals between other TB clinics where HIV services are not integrated and existing CT sites to allow

access to HIV screening for TB patients detected at these sites. ICC will allocate resources to cover

transportation cost\s as well as accompaniment for these patients to the CT sites.

Activity 3: ICC will continue to support a mobile team to monitor and supervise the TB/HIV program.

Resources will be used to hire and train a team of specialized counselors, physicians, data managers, and

Activity Narrative: social workers in TB/HIV and to support their travel to different sites.

Activity 4: ICC will participate in all national efforts to further develop and review the norms, protocols,

guidelines, and training tools for TB/HIV with emphasis on those related to TB infection control and drug

resistance, TB/HIV pediatric care, and program monitoring. Resources will be used for the dissemination of

these documents through the ICC network. ICC will be responsible for implementing and monitoring

infection control measures in its sites according to national norms and guidelines. ICC will also participate

in the national plan of monitoring of TB drug resistance by allocating resources to the sites for tracking of

suspected TB drug resistance cases, collect of sputum specimens from these cases and processing of

these specimens to the National Lab for culture and resistance testing.

Activity 5: ICC will focus on reinforcing Grace Children's Hospital so that it can become a COE. This will

complement GHESKIO's (another COE) efforts to establish Sigueneau Hospital as a COE as well.

Resources will be allocated to Grace Children's Hospital to hire a specialized team of nurses, physicians,

social workers, and data managers that GHESKIO will train as trainers. This team will be responsible for

training providers at Grace Children on TB/HIV in addition to the training undertaken thru GHESKIO. .

Targets:

Number of service outlets providing treatment for tuberculosis (TB) TO HIV-infected individuals (diagnosed

or presumed) in a palliative care setting (a subset of all palliative care outlets): 20

Number of HIV-infected clients attending HIV care/treatment services that are receiving treatment for TB

disease (a subset of all served with palliative care): 2,000 (Male: 1000, Female: 1,000)

Number of individuals trained to provide treatment for TB to HIV-infected individuals (diagnosed or

presumed). (A subset of all trained): 25

.

Emphasis area: Strategic information management, training, human resources, infrastructure, development

of network/linkages/referral systems, community mobilization/participation, QA/QI.

Targeted Populations:

Key legislative Issues:

Coverage Areas: North, South, South East, West, Nippes

Grace Children's Hospital has been receiving assistance from PEPFAR under the umbrella of Management

Sciences for Health, thus this is not a new activity, but the growth of a sub-partner to full partner status as

ICC has been receiving funds in previous years for TB activities.

Integrated Activity: This activity is linked to Activity IDs 18985.08, 18973.08, 17929.08 and 5301.08.

SUMMARY :

International Child Care is an NGO that runs Grace Children's Hospital (GCH) in Port au Prince and

provides support to 137 stand-alone TB clinics. Grace Children's Hospital has been receiving support from

PEPFAR in previous years as part of the MSH umbrella. In 2008, however, due to the demonstrated quality

work, ICC will receive funding directly from USG for GCH and 7 of the 137 TB clinics. This funding will

expand the current counseling and testing program and offer to every patient at GCH and TB clinics, quality

counseling and testing services, including palliative care and ARVs at GCH. To successfully achieve this

goal, the focus will be on strengthening, creating or modifying the following: community mobilization /

participation, information, education and communication. The project will improve the level of care and

services that are provided to those living in the Delmas municipality. GCH implemented the 100% provider-

initiated (i.e. all providers offer testing to all patients) strategy from January-March 2007 and increased the

number of tested persons from an average of 500 at the beginning of the program to 2,173 in May 2007.

During the same period, the number of HIV positive patients increased from 70 to 140. This same strategy

will be initiated in 2008 at 7 of the 137 TB clinics supported by ICC.

BACKGROUND:

GCH began a voluntary counseling and testing (VCT) program in August 2003, although counseling and

testing services were available for pregnant women, TB patients, and other patients with sexually

transmitted diseases toward the end of 1990. GCH is one of the most frequented health facilities in the

country. It receives references for multiple HIV related service issues including VCT, Palliative Care and

anti-retroviral (ARV) services from a number of different health centers. GCH coordinates their

interventions and programs with a wide range of other organizations including other PEPFAR partners. With

all health care providers offering HIV testing to all patients, GCH greatly increased the number of diagnosed

HIV positive patients.

ACTIVITY 1

ICC will expand Counseling and Testing services at GCH, and make counseling and testing services

readily available to all people visiting the hospital. In order to provide adequate space for this activity, GCH

will need to renovate three additional rooms to accommodate HIV patients using the hospital.

ACTIVITY II

ICC will work with GCH to promote community mobilization, such that GCH is recognized as the area leader

in issues related to HIV testing and care. Emphasis will be placed on messages addressing gender equity,

stigma, and discrimination. To facilitate service utilization, GCH will provide quick and easy access to

transportation, and provide support to patients living in slum areas.

ACTIVITY III

ICC will emphasize tuberculosis, HIV/ AIDS and TB/ HIV problems through meetings at GCH as well as 7

TB clinics using community groups, schools, churches, and mass media. They will produce informational

materials focusing on making behavioral changes. These sites will produce didactic material and use

audiovisual equipment in waiting rooms to facilitate the transmission of information. Lastly, GCH will

renovate its' waiting room to better accommodate its clients.

EXPECTED RESULTS

TARGETING TO:

Conduct HIV testing for 30, 000 people (5000 children/parents and 25000 adults) and provide 30,000

individual post-test counseling.

Train in counseling 49 medical and paramedical staff: 7 physicians, 21 nurses, 18 auxiliary-nurses, 2

counselors, 1 psychologist.

Train in HIV testing 5 lab-technicians and 5 bacilloscopists.

Continuing education to 16 counselors, four lab-technicians, 35 visiting-nurses, 27 field agents, 35 health

collaborators.

NOTE: This is not a new activity. In previous COPs, funding for Grace Children's Hospital was provided

through the umbrella organization, Management Sciences for Health, even though CDC has a COAG with

ICC. This year, funding will be provided directly for Grace Children's Hospital through ICC, so this is not a

new activity.

Integrated Activity: This activity is linked to Activity IDs 18985.08, 17929.08, 18957.08 and 5301.08.

SUMMARY: With Fiscal Year (FY) 2008 resources, ICC will contribute to the expansion of ARV services

through Grace Children's Hospital, launched three years ago with funding from the President's Emergency

Plan for AIDS Relief (PEPFAR) to reach 1,000 people living with HIV/AIDS (PLWHA) by the end of

September 2009 in the Port-au-Prince metropolitan. This program will be linked with the TB/HIV, palliative

care, CT, and PMTCT services that Grace Children's Hospital is expanding. It will be also linked to other

community-based programs (CBO) that are being offered through CBOs in the same geographic area. The

target populations include people living with HIV/AIDS and their families.

BACKGROUND: ICC is a key player in the system of care in Haiti. They are well known for their important

role in supporting the TB program throughout Haiti. Through Grace Children's Hospital, an affiliated non-

governmental organization (NGO) hospital, ICC provides specialized TB care, integrated with primary and

general care for both adult and children, with support from USAID and the Global Fund to Fight AIDS,

Tuberculosis and Malaria (GFATM). Since the launch of PEPFAR, the United States Government (USG)

has provided resources to ICC to integrate HIV in its network of TB sites. Resources are also given to

support integrated basic care and anti-retroviral (ARV) services at Grace Children's Hospital and to

implement a pilot model of HIV pediatric care. So far this program has been very successful in enrolling

1,000 patients in care; 300 HIV positive pregnant women in PMTCT; 400 patients, including 100 children in

treatment; and 150 HIV patients in TB treatment services. The USG believes these results will further

increase with FY 2007 resources, while steps are being taken to improve the quality of clinical based

programs nationwide through a better system of QA/QI.

In FY 2008, the USG will continue to provide resources through ICC to make Grace Children's Hospital a

center of excellence for integrated TB/HIV, CT, PMTCT, palliative care, and ARV services in the

metropolitan area. This effort will complement other efforts made through GHESKIO and the MOH to

establish a network of institutions (among the biggest ones with high volume of patients) offering integrated

ARV to three million people Through this program, ICC will continue to ensure—through Grace Children's

Hospital—that all HIV positive people eligible for ARV treatment receive access to clinical, biological,

nutritional and psycho-social assessments and services, using CT, PMTCT and basic care services as a

means of enrolling patients. ICC will continue to build on its important TB program at Grace Children's

Hospital to deliver ARV services to TB patients in need of these services. ICC will continue to strengthen its

model of pediatric care to become a training center for this program. Lastly, ICC will also continue to build

on Grace Children's Hospital's child survival program—supported by USAID—which covers about 100,000

people. As the ARV program will be expanded in FY 2008, ICC will place more emphasis on quality

improvement to ensure the best quality of care to patients.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Funding will be used to maintain and expand at Grace Children's Hospital, a multidisciplinary staff

of physicians, nurses, psychologists, social workers, counselors, nutritionists, community health workers

and laboratory technicians. Resources will also be used to support enhancement of infrastructure,

equipment, materials and supplies for service organizations at clinics, laboratories, and the pharmacy and

for X-ray service. This will be done in integration with other resources allocated for CT, PMTCT, TB/HIV and

basic care service through ICC for Grace Children's Hospital. Linkages will be established with SCMS to

provide ARV drugs, laboratory reagents, and commodities.

Activity 2: ICC will reinforce its capacity with treatment and psycho-social specialists to oversee and provide

supervision to the program in integration with other HIV services. ICC will receive additional support from

GHESKIO for training and mentoring on best practices for providing HAART to TB patients. These

specialists will ensure that the clinical and community staff receive continuous training to acquire and

maintain necessary skills in the care and treatment of people infected with HIV/AIDS. They will also help to

address patients' medical and psycho-social problems that require expert intervention at ARV sites.

Activity 3: Linkages will be maintained between the ARV services and the CT, basic care, PMTCT and TB

services to ensure a continuum of care to patients. In addition, these ARV services will be linked to CBOs

and PLWHA support groups to provide integrated community support for patients enrolled in treatment.

Activity 4: Funding will be used to strengthen the pediatric ward to expand ARV pediatric care and treatment

services building on the pilot experience launched at Grace Children's Hospital two years ago. Human and

logistic capacity will be reinforced at this ward to offer hands on training for other institutions.

Activity 5: ICC will also include on its team data quality managers that will work in coordination with MOH,

CDC, and HIVQUAL to integrate in its TB/HIV network, tools to assess quality data and a process of

continuing QA/QI.

TARGETS:

Number of patients ever received ARV: 1300

Number of patients active on ARV: 1000

Number of outlet offering ARV services: 1

Number of health professionals trained in pediatric care: 20