PMTCT Baseline Assessment and Planning Template (Haiti)

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In response to the U.S. government’s Presidential Initiative on PMTCT, and the mandates of both CDC/GAP and USAID to support national scale-up of PMTCT activities in designated countries, CDC and USAID HQ’s ask that country offices work together and directly with the Ministry of Health, the national PMTCT steering committee (or similar group), and key multilateral and bilateral PMTCT stakeholders and NGO’s to provide as much as possible of the requested background information on MCH services, current and planned PMTCT activities, and proposed roles of CDC and USAID in supporting enhanced PMTCT scale-up activities.

''This template is designed to be useful for in-country PMTCT assessment and planning. We would welcome comments and modifications/ additions relevant to your country situation. As with the President’s Initiative itself, it’s important that this assessment and planning process to be undertaken with the direct participation and support of the Ministry of Health and relevant stakeholders.'' Country:

 * Indicate who will coordinate final submission of this assessment: ____

Demographics
Please provide the following information (some data likely to be rough estimates)

______________________ $1$Population in 2002 calculated using an increase rate : 1,028% $2$Calculated using crude birth rate of 32,7 per thousand $$Using estimation established by Sentinel Surveillance Method for pregnant women, 1999-2000.

$$ Births x HIV prevalence x estimated background HIV transmission rate. What is commonly used as background MTCT transmission rate in your country: _________% Comments:  $3$  Calculated using crude birth rate of 32.7 per thousand @  Using sentinel surveillance method for pregnant women, 1999-2000. $$ IHSI: Haitian Institute for Statistics

2. Maternal and Child Health (MCH) Facilities
By Sector and by Number of Facilities Currently Providing PMTCT Services Please provide information regarding the estimates number of deliveries by health and distribution of health facilities providing MCH care (outpatient ANC only or full maternity/delivery services) and PMTCT services in your country. If reasonable estimate is not available, please provide approximate range.

$st$ Includes non faith-based private hospitals and clinics. ______________________ $1$ Private=Mixte + Private only

$2$ Providing some or all of the following services: ANC, HIV counseling and testing (C&T), antiretroviral prophylaxis to prevent mother to child transmission, infant feeding counseling, provision of infant formula.

Part 2. Current PMTCT Policies, Programs, Materials
PMTCT Policy Is there a national PMTCT policy? Yes__________________________No____________ If no, is there a target date for developing a policy? [please answer and skip to #2] 31 March 2003 (see attached framework) If yes, please complete the following: Date of policy? N/A Official or draft? N/A Copy available and attached? N/A Briefly summarize the key points: N/A Is there a target goal or recognized need for new or updated PMTCT policies? If yes, explain: The National Strategic Plan for HIV/AIDS 2002-2006 calls for theimplementation of PMTCT services in a maximum of health settings to serve alarge number of HIV + pregnant women in Haiti. PMTCT Guidelines. Are there national PMTCT guidelines? Yes ______             No_______ If no, is there a target date for developing guidelines? [please answer and skip to #3] If yes, please complete the following: Date of guidelines? 1999 These guidelines are still in draft and are currently being updated. Official or ? Copy available and attached? Yes (see attached guidelines draft) Briefly summarize the key points: In the 1999 draft, all HIV+ pregnant women and their new born would be '''eligible to receive an AZT regimen according to the Thailand guidelines. In 2001, the Ministry of Health''' agreed to accept nevirapine as analternative for women who enrolled in the program late in pregnancy. Is there a target goal or recognizedneed for new or updated PMTCT guidelines? If yes, explain: Haiti needs to add nevirapine to the ARV choices – In addition, debates on newborn feeding(breastfeeding vs. infant '''formula) need to be resolved. Finally, there needs to be a consensus ondelivery modes (normal or C section).'''

PMTCT Policy or Guidelines problem areas. Are there key "problem areas" in the current PMTCT policy or guidelines, or "problem areas" that are blocking consensus or clarity in the development of guidelines. &mdash; Antenatal clinic and HIV screening for remote populations ofpregnant women &mdash; Mode of delivery (normal vs C section) &mdash; Place of delivery (home delivery vs hospital delivery) &mdash; Infant feeding (breastfeeding vs infant formula) &mdash; Management of mothers becoming symptomatic after delivery PMTCT Steering Committee Is there a national PMTCT steering committee? Yes ______    No_______ If no, is there a targetdate for establishing a steering committee? (Please answer and skip to "c") If yes, please complete the following: What group chairs the steeringcommittee? MOH is chair, UNAIDS is co-chair What organizations (ministry agencies ordivisions, stakeholders) participate on the steering committee? &mdash; Ministry of Health &mdash; Ministry of Social Affairs &mdash; Ministry of Women Affairs and Rights &mdash; PAHO &mdash; UNFPA &mdash; UNICEF &mdash; UNAIDS &mdash; CDC/GAP &mdash; USAID &mdash; FHI &mdash; JHPIEGO &mdash; MSH/HS-2004 &mdash; GHESKIO &mdash; IHE &mdash; MARCH &mdash; PIH/ZL &mdash; CARE &mdash; Médecin du Monde &mdash; ACDI Comment on the relative strengths andweaknesses of the steering committee. Strength: &mdash; Coordination allows each organization to contribute according toits area of expertise &mdash; Great level of commitment of each participatingorganization. Weakness: &mdash; Difficulty to establish consensus on some technical issues(bottle feeding with formula vs breastfeeding, AZT vs Nevirapine, Monotherapyvs bitherapy or tritherapy). &mdash; Lack of coordination in funds disbursement &mdash; Management of supply &mdash; Supervision of activities &mdash;Absence of a Monitoring System Comment on the potential need for additional support to strengthen the steering committee? (What additional capacity might be needed to assure the good functioning of the steeringcommittee? How could the President’s Initiative help with this?) &mdash; MOH/UCC leadership capacity building &mdash; Organization development/Strengthening of coordination amongpartners &mdash; Others: dissemination of lessons learned and best practices,Inter Caribbean liaison,   Drugs forSTI, OI and MDRTB.

National PMTCT plan Is there a national PMTCT plan (for implementation, expansion,scale-up)? Yes ______      No _______ A PMTCT national plan is beingelaborated and will be ready by March 31, 2003 If yes, briefly describe: ii. What are the target goals, timeline,and steps for scale-up to a national program? '''There was a pilot project targeting 400 HIV+ pregnant women. Aplan to provide universal access to all HIV pregnant women will be elaboratedby March 2003.''' National PMTCT program Is there a national PMTCT program? Yes ____ ___      No _______ If yes, briefly describe (includingtype of program, approximate coverage, approximate uptake) What strategies are in place forimproving current coverage? Basic PMTCT regimen  What is the basic PMTCT regimen? ____  Single dose NVP ____  Short-course AZT ____ Single dose NVP and short-course AZT If applicable, comment on issuesrelevant to regimen in your country: &mdash; Many HIV+ pregnant women do not seek Prenatal Care or arrive toolate to be eligible for the AZT '''regimen. Thus, Nevirapine has been adopted as an alternative regimen.''' &mdash; '''There is little access to obstetrical services. Most of the deliveries (75%) are still at home.''' &mdash; Stigmatization by health personnel. NVP Drug Access Is there an agreement withBoehringer-Ingelheim to participate in the Nevirapine drug access Initiative in your country? Yes _____     No_______      No, but beingdeveloped _________ If yes, how much NVP is being provided by B-I (or Axios) (annually)? AXIOS notified UNAIDS that Haiti will receive 5000 rapid tests (Determine) this year with an increase of 5-10% per year for 5years (2007). Haiti is expecting a response on its request for Nevirapine. Briefly comment on whether this is going well (is drug getting into thecountry? Is it getting to the sites?) Rapid Testing  Is rapid testing / same-day results being provided in PMTCT antenatal settings? ___ Yes &mdash; this is basic recommended program __Yes &mdash; in some sites but not all ___ No &mdash; not yet implemented ___ No &mdash; not recommended/ not approved in-country

"PMTCT &mdash; PLUS" Is there a plan to implement PMTCT&mdash;PLUS (PMTCT care and treatment to HIV+  mothers, infants, partners)? Briefly describe what is currently in placeand what is being planned. '''Yes. PMTCT- Plus will be implemented in one of the nine Health Departments through GFATM.''' Implementation of the GFATM will begin in March2003. Have PMTCT-PLUS grants from Columbia/Rockefeller been awarded for specific sites? Briefly describe sites and source of support. No Are there other sources of funding andproject plans for “PMTCT-PLUS” (eg. Global Fund, national budget, etc)? '''GFATM will provide funds for PMTCT – Plus on a limited scale. USAID and CDC have plans for''' expansion of the PMTCT – Plus initiative but no funds currently available. PMTCT Center of Excellence  Is there a PMTCT Center of Excellence(demonstration project, center for systems development and training) or plan for PMTCT Center of Excellence, for operations and training? Yes ______      No_______ Comment (status, brief summary, degreeof completeness, need for technical assistance, etc.): GHESKIO / PIH/Zanmi Lasante (Cange), CHOSCAL are sites for thepilot project targeting 400 HIV+ '''pregnant women. The success of their interventions has motivated plans for the extension of PMTCT''' activities by the MOH. PMTCT Program Manual Is there a PMTCT Program Manual orImplementation Guide? Yes ______      No _______ Comment (status, brief summary, degreeof completeness, need for technical assistance, etc.): We request technical assistance in the development of a PMTCTprogram manual / implementation guide. PMTCT Training Curriculum Is there a PMTCT training curriculum andtraining program? Yes ______      No_______ Comment (status, brief summary, degreeof completeness, need for technical assistance, etc.): '''GHESKIO is currently the training center for PMTCT. It developed a training curriculum that has''' replicated their pilot project experience.

Part 3. ARVCare and Treatment
Is there a plan to provide ARV care and treatment to HIV-infected persons, as part of demonstration project or national program? Briefly describe what is currently in place and what is being planned. '''Yes. PIH/Zanmi Lasante is providing ARV treatment to a limited number of around 400 AIDS patients.''' Through its grant from GFATM, it will extend ARV access to a entire health department. CDC GAP and possibly USAID will support MOH in its project to implement at least one Care and Treatment Center in one public Hospital byDecember 2003. Has there been training in-country on ARV use for doctors and nurses? Is more training needed? If yes, what type of training would be most useful, and what would be the best way to provide this training? '''Yes. One (1) national training center at GHESKIO. More training is needed in counseling &mdash; ARV''' management &mdash; diagnosis and treatment of opportunistic infections &mdash; home-based care and treatment.

Eleven (11) What is the estimated number of medical centers where ARV drugs are currently being provided? Five (5): GHESKIO, PIH/Zanmi Lasante, CHOSCAL, Albert Schweitzer Hospital, Port-de-Paix hospital, Carrefour hospital, Lumière hospital, Lascahobas hospital, Belladère hospital, Thomonde HealthCenter, '''Claire Heureuse hospital. The last seven medical centers began their ARV program very recently.''' With technical assistance and training, what would be a reasonable number of hospitals that could support an ARV program in the first 1-2 years of an expanded program? USAID and CDC-GAP is currently working with GHESKIO and the MOH to put in place 27 (public and '''private) VCT centers throughout Haiti. There has been a large demand from other medical centers''' '''to become part of the national VCT program. Many of these centers will become part of the national plan in''' '''the next year. Thus, we estimate that within the next two years, 30 hospitals including the 27 VCT centers''' could support ARV program if the necessary technical assistance becomes available. What is the estimated number of HIV-infected adults currently receiving ARV care? '''No reliable data available. An estimated number of 500 patients are receiving ARV care.''' Has specific funding support been obtained for treatment programs? Briefly describe. PHI/Zanmi lasante has obtained funds from GFATM for a treatment program in favour of one (1) entire health department (around 2000 AIDS patients). Have reduced price agreements been established between the government and international pharmaceutical companies? If yes, please briefly describe. Yes- Through CARICOM agreements with 7 Pharmaceuticals Firms are in place. Are generic ARV drugs approved for use in-country? Are they being used? Describe. No. The approval process has begun. Are generic ARV drugs produced in-country? Describe. No If more ARV’s became available through outside program support, would the current drug distribution system (through central pharmacy or some other mechanism) be adequate to handle increased ARV distribution? If no, briefly describe the type of support that would be needed to facilitate large-scale ARV distribution. '''Yes. ARV could be distributed through the existing central pharmacy (PROMESS). However extensive''' tecnical (sic) assistance would be necessary to ensure proper management and distribution of these drugs.

Part 4. Global Fund
What is the status of Global Fund Applications for your country? __  Awarded (on HIV/AIDS) _  New application recentlysubmitted. The new application submitted for TB amd Malaria has been declined __X__  Plan to submit application for next round ____   Nocurrent plans to submit application If awarded or recently submitted, please briefly describe the key points: &mdash; Main objectives of the proposal &mdash; Reduce the risks of HIV infection &mdash; Reduce the vulnerability to HIV/AIDS &mdash; Reduce the impact of HIV/AIDS on individuals and their families &mdash; Main objectives and plan for PMTCT Provide access to PMTCT services to all HIV+ pregnant women living in 25 VCT target populations &mdash; Main objectives and plan for ARV’s

Provide access to ARV treatment to all HIV+ persons living in the Central Plateau Department (PIH/Zanmi lasante area) &mdash; Overall amount of funds awarded or requested US$66,905,477.00 &mdash; Amount of funds for PMTCT Not defined &mdash; Amount of funds for ARV’s US$10 million How best could the President’s PMTCT Initiative be coordinated with and enhance proposed Global Fund PMTCT activities? To complement the national resources for a national coverage of all HIV+ pregnant women.

Part 5. Twinning and Volunteer Medical Corps (VMC)
One aspect of the President’s PMTCT Initiative is the proposal to support human resource capacity building and training through "twinning" of U.S. medical centers and institutions with local institutions in country, and to develop systems for health professional volunteers to work in country (eg. through faith-based organizations, Peace Corps, professional organizations, universities, etc.). Currently, are there "twinning" or volunteer programs supporting PMTCT and/or care? If yes, briefly describe the types of programs, which institutions are involved, and whether the program is viewed as helpful/successful. '''Yes. Cornell University / GHESKIO, Harvard University / Partners in Health / Zanmi lasante. Both of''' these programs have been successful. What institutional relationships (either within public health, or in other fields such as social science, economic development, etc.) already exist in-country that might be the basis of a twinning/VMC effort? Tulane University / MARCH

Part 6. Key PMTCT Program Implementers/ Stakeholders
Briefly describe current implementation and program support efforts being undertaken by the national government and by various stakeholders. 1.    Government (major activities, funding, staffing,specific PMTCT sites, etc) Not yet available For each of the following agencies/ organizations active in PMTCT in your country, please include a brief narrative including: major roles and activities related to PMTCT program support; clinics and approximate number of clients directly being supported or co-supported; main partners and mechanisms of support, approximate level of funding for PMTCT, participation in PMTCT steering group activities, etc). Particularly for CDC/GAP and USAID, this should essentially be a short summary of current and planned PMTCT support activities. It would be helpful to have similar brief summaries for the other active stakeholders as well. 2.     GHESKIO           A group of Haitian doctors concerned with the newly evident HIV epidemic in Haiti created the GHESKIO centers in 1982. GHESKIO is the second oldest HIV/AIDS research center in the world after the Centers for Diseases Control in Atlanta. GHESKIO is one the 19 center (sic) for the NIH-led vaccine trials for HIV and was recently rated by NIH as the second highest in quality of research and care of all the centers.           In addition to research, GHESKIO delivers health and social services to over 7,000 new clients annually. Services include: testing, treatment, counseling and prevention education for HIV, STIs, TB, diarrheal disease and since 3 years PMTCT care. GHESKIO has been chosen by the MOH as one of the three sites for the PMTCT pilot project in Haiti. With USAID and CDC support GHESKIO is now the training center for the PMTCT expansion in Haiti. USAID has supported GHESKIO since 1983.

3.    HAS The Albert Schweitzer Hospital (HAS) is a private non-governmental organization founded in 1954 by the late American philanthropists, Dr Lorimer Mellon and his wife Gwendolyn Grant Mellon. Almost50 years later HAS continues to provide quality curative health care services from the impressive 116-bed hospital to 225,000 inhabitants. HAS reports seeing over 100,000 outpatients annually throughout their network, which includes twelve dispensaries. HAS promotes an integrated health care system with emphasis on health education, public health, and community health. It also launched community development activities from agriculture and reforestation to potable water systems and micro-credit activities. Hospital operations are financially supported by private donations made through the Grant Foundation. HAS also attracts funding from numerous private foundations including 2.5 million from the William Gates Foundation. Financing HAS/community health program, USAID through HS-2004 supports services to a population of nearly 150,000. HAS community health program boasts a fully immunized rate of 82% for children under 1 (compared with the national average 34%), a rate of 76% for 3 or more prenatal visits, and 83% of all births are attended by a trained medical medical (sic) professional (compared with the national average 80% of home-based delivery by TBA). With UNICEF’s support, HAS has just started PMTC activities MARCH MARCH, a private Haitian foundation, is the third largest healthcare provider in Haiti. It operates a network of hospitals and community-based services in four distinct geographic zones of Haiti: the Port au Prince metropolitan area, the lower Central Plateau, the northern and southern coasts of the southern peninsula. Within these areas, MARCH reaches a population estimated at 500,000 people. It provides comprehensive health services including reproductive health services with a particular focus on young women. It has very busy obstetric and family planning programs at its hospitals. With regard to HIV/AIDS, MARCH has developed a variant of the peer-to-peer approach that uses lessons learned from the positive deviant methodology in nutrition as applied to HIV/AIDS prevention: young women with safe sex practices participate in self-selected small peer groups used to provide emotional and psychological support to group members so that they can maintain their safe sex practices in the face of external pressures to do the opposite. MARCH just an application to obtain support from USAID and CDC to start PMTCT activities in its populations. PIH/ZL Partners in Health (PIH) is a non profit organization affiliated with Harvard Medical School. PIH and Zanmi lasante (ZL), its Haitian partner organization, have been working in Haiti’s Central Plateau area for over 15 years. By 1998, PIH had begun the "HIV Equity Initiative" to develop a truly comprehensive AIDS program. As part of this initiative, PIH/ZL began providing HAART to a small number of patients with advanced AIDS who no longer responded to the treatment of opportunistic infections. To ensure complinace (sic) drug regimens, PHI/ZL employed a variation of the directly observed therapy (DOT) strategy commonly used for TB treatment. PIH is a major partner in the newly awarded $66 million grant to Haiti from GFATM. Over the five next years, PIH/ZL will scale up their existing DOT-HAART program to provide comprehensive AIDS and TB services for symptomatic AIDS patients throughout the Central Plateau Region. PIH/ZL also is one of the three sites of the PMTCT pilot project in Haiti. HIV + pregnant women attended in PIH/ZL health settings will have access to HAART when they will become (sic) symptomatic. CBP The Welfare Committee of Pignon (Comité de Bienfaisance de Pignon, CBP) is a non-governmental organization originally established in 1980 to provide curative health services to 35,000 in the community of Pignon, located in Haiti’s Central Plateau area. Today, CBP is one of the Haiti’s most successful, comprehensive health and development programs serving a population of over 167,000 people. In addition to the hospital in Pignon, CBP has an extensive community outreach program including not only traditional service delivery, but also breastfeeding promotion, Tuberculosis prevention and treatment, and AIDS prevention and screening. CBP works with community health workers, traditional health practitioners, traditional birth attendance, mother’s clubs and rural women’s credit groups to create an extensive community network to reach rural, economically compromised populations. USAID has provided assistance to Pignon since 1983, with current assistance averaging $350,000. CBP is one the health organization (sic) targeted for collaboration should funds become available for the expansion of PMTCT.

CHOSCAL CHOSCAL is a public hospital in the national curative health system. It is located in Cite Soleil the largest slum area at the northern entry of Port au Prince. CHOSCAL also was one of the three sites of the PMTCT pilot project. To implement this PMTCT at CHOSCAL, the MOH has obtained the collaboration of Médecins du Monde/Canada (MDM/Canada). Despite MDM’s efforts, the project at CHOSCAL has not had the same success as GHESKIO and PIH/ZL. PSI PSI is a non-governmental organization currently involved in the Social Marketing of Condoms and hormonal contraceptives since its arrival in Haiti. For almost 10 years, it has been more active in HIV/AIDS prevention by adding to the SMC a large number of activities such as behavior change communication including mass media, peer educators, and community-based groups. Recently PSI proposed to USAID a two-phase pilot MTCT project. To carry out this project, PSI has established a large partnership with MOH, PAHO, GHESKIO, FHI/Impact, AOPS, and INHSAC. CHI CHI, a non governmental organization, has a well known experience on (sic) monitoring/evaluation. CHI has been designated by the Ministry of Health to undertake the needs Assessment and Monitoring of the PMTCT program. CHI has already undertaken needs assessment for 13 clinics and has just completed a Situational Analysis of PMTCT in Haïti. CARE CARE, on the request of the MOH is being involved in the PMTCT program in Port-de-Paix and Jeremie areas with the financial assistance of UNICEF. Care and support to PWAS and orphans are parts of this project

Part 7. Key PMTCT Program Components, priorities and Needs (MSPP/GHESKIO)
Building and Facilities Has the ability to renovate or built facilities to support PMTCT activities USAID, FHI, CDC, UNICEF, ACDI, USAID, HS-2004 In process Yes Better identification of needs and maintenance procedures ANC Counseling and Testing (C & T) Provides or has the potential to provides ANC C&T GHESKIO, CANGE, HHF, CHOSCAL, PIH, HAS, CARE In process Yes Development of a guideline manual Antiretroviral (ARV) Drugs (purchase/store/ Distribute) Currently purchase, stores, or distributes (or has the potential to purchase, store or  distribute) drugs to hospitals and clinics PROMESS, PSI, AXIOS, ONUSIDA, UNICEF In process Yes Procurement strategies and distribution of drugs ARV Drugs (dispense) Currently dispenses or has the potential to dispense ARV prophylaxis (eg. NVP, AZT) for  PMTCT to individual mothers GHESKIO, CANGE, HAS, CHOSCAL, CARE Yes Techniques to improve compliance and patient management