This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), HIV/TB (#10057 ), Counseling and Testing (#10062 ), Strategic Information (#10074) and Policy (#10337).

Since 2005, the EP has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the Ministry of Health in supporting and expanding quality PMTCT in Cote d'Ivoire while building on and complementing other programs supported by the EP, Global Fund, UNICEF, and others. EGPAF is the EP's primary partner for PMTCT services in Cote d'Ivoire. The EP has supported EGPAF in developing a holistic, family-centered approach to HIV prevention, care, and treatment within the health sector.

EGPAF provides direct support to PMTCT sites to ensure that national standards are met. This support covers needs of commodities, equipment, trained staff, laboratory services, and mother-infant follow-up. Implementation requires close coordination with the national HIV care program (PNPEC) and will be done in public sites or through performance-based sub-contracts. EGPAF also seeks partnerships to provide continuum-of-care services at the community and home levels through organizations such as Alliance National CI, CARE International, and ANADER.

EGPAF is committed to building national capacity within public and NGO/CBO/FBO organizations to support quality sustainable PMTCT services. The graduation of a major EGPAF sub-partner, the Ivorian health-professional NGO ACONDA, to direct EP partner status with a new award in 2006 represents a concrete example of EGPAF's effectiveness. EGPAF seeks to provide technical assistance to upcoming EP PMTCT partners, including those that may join through the New Partners Initiative. EGPAF will help decentralize HIV services while building the capacity of other partners to carry the effort further.

With FY05 funds, EGPAF supported the MOH to strengthen national PMTCT policies and systems and to provide PMTCT services at 56 sites. EGPAF's work in FY05 laid the groundwork for a rapid acceleration of service delivery in FY06, and EGPAF is on target to fulfill its COP06 commitments. With FY06 funds, EGPAF: 1. Supported PMTCT activities at 56 sites with ACONDA. ACONDA gradually increased ownership of 21 sites and will run them as a prime partner in FY07. 2. Provided technical and financial assistance to update and disseminate the national PMTCT policy and guidelines, including combination ARV prophylaxis and routine HIV counseling and testing (CT). 3. Expanded PMTCT services to 39 sites, most through performance-based, competitive sub-contracts. 4. Improved the quality of PMTCT services at all 95 sites receiving direct site-level support from EGPAF, achieving better uptake at every level of the PMTCT-plus cascade (CT, results, prophylaxis, and follow-up). By the end of the period, at least 95% of women tested received their test results, and at least 90% of HIV-positive women received ARV prophylaxis. EGPAF and its partners also improved follow-up and strengthened referrals for HIV-positive mothers and infants. 5. Promoted innovative approaches to support: provider-initiated routine CT, HIV rapid testing in labor and delivery, longitudinal postnatal follow-up of mother-infant pairs, promotion of a family-centered approach emphasizing links to CT and care and treatment for infected mothers, infants, and family members, early infant diagnosis (PCR using dry blood spot), use of a simplified HIV testing algorithm, and ongoing documentation and sharing of experiences to inform rapid national scale-up. 6. Strengthened PMTCT monitoring and evaluation systems at national, district, and site levels in collaboration with key partners. 7. Strengthened nutritional counselling by health workers for antenatal and postpartum HIV-infected women, including counselling on early weaning and culturally appropriate replacement foods, with support from EGPAF sub-partner PATH and the national HIV-nutrition technical working group. 8. Strengthened the capacity of local partners to improve organizational management, M&E, and quality of services with continued performance-based contracting. 9. Strengthened partnerships with national health-professional associations (paediatrics, obstetrics/gynecology, and midwifery), the MOH HIV care and reproductive-health programs, and district health teams to improve ownership, training, and supervision of integrated PMTCT services by key stakeholders. 10. Integrated routine testing at all PMTCT sites in Abidjan, complementing expanded CT

in family-planning, TB, and HIV care and treatment sites (described in the CT and HIV/TB sections.)

With fY07 and plus up funds, EGPAF will expand the number of PMTCT sites receiving direct support from 95 to 145, specially in the underserved North, which will provide services to 200,000 additional patients, and will continue to improve the quality of services provided at the sites. An estimated 1,500 women will be referred to treatment sites as continuum-of-care activities in these hard-to-reach settings are strengthened. The plus up funds will include $200,000 B31 for nutrition support by Helen Keller International. PMTCT activities will be expanded within districts currently implementing PMTCT activities and extended to underserved regions according to the directives of the MOH national HIV care program. EGPAF will provide CT with tests results to 125,000 pregnant women; provide at least 8,750 HIV-infected pregnant women with TB screening and ARV prophylaxis or, if indicated, HAART (anticipating at least 500 immuno-compromised women in need of HIV treatment); and diagnose and follow 500 HIV-infected children.

EGPAF and its partners will also work to further develop the family-based approach that links PMTCT services with comprehensive CT, care, and ART for all family members. A high priority will be identification of HIV-exposed children and their siblings for pediatric care, treatment, and linkages to OVC programs. HIV testing of HIV-exposed children using PCR DBS will increase the detection rate of HIV-infected children in need of care through PMTCT-plus programs.

EGPAF will continue to work with the MOH, UNICEF, ACONDA, and other partners to refine overall national policies, guidelines, and plans for scaling-up PMTCT and associated services. EGPAF and ACONDA will coordinate as the ACONDA program splits off to become an independent prime partner under the EP, and they will coordinate the scale-up of their programs with the MOH in strategic geographic areas. EGPAF will also continue to coordinate with SCMS, which is fully responsible for procurement of EP commodities for the central warehouse. Laboratory services in support of PMTCT services will be coordinated with APHL, CDC/Project RETRO-CI, and the national network of laboratories as part of the national HIV program.

EGPAF will also work with the RETRO-CI lab and APHL (infant diagnosis, QA for HIV testing and laboratory supervision); HIV/AIDS Alliance CI, ANADER, and CARE International (linkages with community mobilization and psychosocial support through community workers and PLWHA); FHI (linkages with social education and OVC); Measure/JSI (M&E); and PATH, Helen Keller International Foundation, and WFP (nutritional support). EGPAF will collaborate with the National Reproductive Health Program and UNFPA programs to link reproductive-health services and HIV CT. Technical support from JHU/CCP will continue for the development or adaptation of job aids, client information, and other materials.

EGPAF will continue to build on innovative approaches to training in infant feeding, nutritional support, early infant diagnosis, linkages to postpartum services, and couples testing in PMTCT settings. A proposed targeted evaluation will assess the reliability of HIV rapid tests as a screening tool for infants starting at 9 months.

This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), HIV/TB (#10057 ), CT (#10062 ), SI (#10074), and Other/Policy & Systems (#10337).

Since 2005, the EP has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the Ministry of Health (MOH) to support and expand quality care and treatment services in Cote d'Ivoire while building on and complementing other activities funded by EP, Global Fund, UNICEF and others. The EP has supported EGPAF's Project HEART to develop a holistic, family-centered approach to HIV prevention, care, and treatment within the health sector.

In September 2006, with support from EP partners including FHI, EGPAF, and ACONDA, the MOH developed a national palliative-care policy along with a list of essential OI drugs adapted to different health-care and community settings. EP partners have been encouraged to provide a preventive and care package of services to all HIV-infected individuals. Project HEART has advocated and worked for a consensus on a standardized package of care that it can make available at all of the sites it supports and that is affordable and consistent with national policies. EGPAF will provide free cotrimoxazole with FY06 funds, and the national program has access to fluconazole thanks to Pfizer's national donation program. Other products, including bednets and condoms, will be provided with support from the Partnership (SCMS) as part of a prevention and treatment package.

International and local studies provide evidence that the key opportunistic infections that contribute to preventable mortality among HIV-infected persons are TB, bacteremia, and cerebral toxoplasmosis. Of note, the high cost of certain FDA-approved drugs used to treat severe OIs, coupled with constraints on EP funds and the costs borne by the client in the absence of national subsidies, limit Project HEART's capacity to provide comprehensive OI treatment services to PLWHA, including HIV-positive, non-ART-eligible individuals.

To date, EGPAF has provided medical and supportive services to 26,858 patients, 12,451 HIV-positive pregnant women, and 3,740 TB/HIV co-infected patients, yielding a total of 33,700 HIV-positive persons receiving palliative care. However, there may be underreporting of services for PLWHA not yet eligible for ARV. Links to community services supported by other EP partners (Alliance, CARE, etc.) has also allowed improved continuum-of-care services and some household outreach. Key wraparound services, including nutritional support, have been possible thanks to a collaboration with WFP.

With FY07 funds, EGPAF plans to provide comprehensive palliative care, including medical, nutritional, and psychosocial support, to 45,000 HIV-positive individuals visiting HIV-care sites, 13,000 at PMTCT sites, and 7,000 at HIV/TB sites, for a total of 65,000 individuals. This is a significant number of patients, given that EGPAF will no longer work through ACONDA, a sub-partner that gave EGPAF significant reach but that will graduate to be a prime partner in FY07. In FY07, EGPAF and ACONDA will coordinate to split up their jointly run sites and will coordinate to scale up in different geographic locations. EGPAF expects that it will reach patients through at least 75 HIV-care sites with FY07 funds. EGPAF will continue to implement its program through the following implementing partners: HOPE Cote d'Ivoire, Saint Camille, Renaissance Sante Bouaké, Centre Wale, El Rapha, Centre SAS, Espace Confiance, SOGB, SAPH, NDA, Ayame Catholic Hospital, Ouangolo Catholic Hospital, and CIRBA. Several more national partners will join the project in late 2006. EGPAF will provide technical support and assistance to all its implementing partners. It will give special attention to strengthening the ability of the partners in management of supplies, commodities orders, and data; monitoring and evaluation; and use of modern technology to improve program management.

EGPAF's work complements the efforts of the Alliance CI, CARE, and FHI, which have ongoing community capacity-building and empowerment activities in the same implementation areas. Alliance CI and EGPAF will have particularly strong linkages between their programs, as Alliance-funded home-based care projects will be linking up with EGPAF clinical sites to provide support in their homes to patients with advanced illness. EGPAF will also continue to work closely with the national HIV, TB, and reproductive health programs, as well as other EP partners (CARE, PSI, ACONDA, and ANADER). These partners have referral systems that usher patients into EGPAF's comprehensive care program.

The specific basic-care package that EGPAF's implementing partners will provide includes free OI prophylaxis with cotrimoxazole, fluconazole (prevention and treatment as per Pfizer donation program), iron supplementation for anemia, Vitamin C, Vitamin A (for children), micronutrients, condoms, oral rehydration salts, safe-water products, and impregnated bednets. At heavily subsidized prices, EGPAF partners will also provide care for intercurrent infections such as malaria, toxoplasmosis, and septicemias. Food supplementation and targeted nutritional support will be provided to malnourished patients, and entire families will receive nutritional support with technical support from PATH and Helen Keller International and food commodities from WFP.

EGPAF will also support activities at the national level in FY07. EGPAF will assist with the development and dissemination of palliative-care guidelines, job aids, brochures, and a training curriculum (in partnership with FHI and Alliance CI). EGPAF will provide training for 300 care providers (physicians, nurses, social workers, and community caregivers) on a complete palliative-care package. EGPAF and its partners will also strengthen the palliative-care network and referral system at all supported ART and PMTCT sites. EGPAF will document the impact of these palliative-care services by tracking patient morbidity/mortality as well as adherence to care and treatment. This information will inform the national policy as part of the program evaluation, with TA from JSI/Boston.

As procurement is planned to be done through SCMS, EGPAF will work closely with this service provider to forecast and develop a procurement plan that will ensure uninterrupted supplies of palliative-related commodities.

This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), CT (#10062 ), SI (#10074), and Other/Policy & Systems (#10337).

With EP support, Project HEART has rapidly established an innovative family-centered approach to provide comprehensive, decentralized HIV prevention, care, and treatment services in Côte d'Ivoire. Integration of TB and HIV services is an overarching goal for Project HEART and the whole EP program. Achieving integration is proposed through provision of routine HIV counseling and testing (CT) services at TB diagnostic sites, provision of TB and HIV care for co-infected patients at TB treatment sites, and TB screening and referral at all HIV service sites.

To date, EGPAF has assisted the Ministry of Health (MOH) to provide routine free HIV testing (moving from an "opt-in" to a routine CT approach at the same sites) in four specialized TB centers in and outside Abidjan, with a case load of more than 10,000 patients out of the annual case load of 18,000 smear-positive TB patients. These activities resulted in improved HIV testing uptake among TB patients and the identification of HIV-infected TB clients in need of joint HIV and TB care. EGPAF is working to strengthen HIV/TB health services with integration of the management of HIV and TB care for co-infected patients. Activities include increasing clinical capacity to provide routine provider-initiated CT services, implementing a functional referral system (linking clinics providing HIV and/or TB diagnosis with those providing HIV and TB care and treatment services), enhancing community-level support to promote adherence and successful treatment outcomes, and care for families of HIV- and TB-affected persons through screening for TB and HIV in the household. EP funds are used to train health-care providers, provide HIV test kits and supplies, perform minor facilities renovation if needed, and provide ARVs through a coordinated procurement process at the national level. In addition, hiring of short-term medical consultants (3-6 months) has helped fill critical human-resource gaps.

With FY06 funds, EGPAF is on track to launch an aggressive expansion effort coupled with improved quality of services to improve detection of, and care for, TB/HIV co-infected patients. Early results include a doubling in the rate of client diagnosis at the main TB center in Adjame over a six-month period. By end June 2006, with EGPAF support, five specialized TB centers and 15 secondary TB diagnosis and treatment centers (DTC) had integrated routine CT, and 3,740 TB/HIV co-infected patients had been diagnosed and had initiated HAART. The increase in patient testing uptake coupled with ongoing expansion of integrated CT services at an additional 33 TB DTC should allow Project HEART to achieve the goal of 5,000 TB patients receiving HIV care by March 2007. However, significant challenges must be overcome, including a lack of trained human resources, resistance from TB/HIV care providers to adopting routine CT with same-day results, inadequate promotion of HIV testing among TB patients, unreliable commodities supplies, and inadequate referral systems for ongoing HIV care and community support.

In support of the national priorities of the TB and HIV programs and in collaboration with the EP and other partners, EGPAF will use FY07 funds to: - Expand routine CT services as part of all TB service sites. - Improve TB/HIV diagnosis (including children) as part of a family-centered approach, with household follow-up for HIV/TB co-infected clients. - Expand HIV treatment services at TB sites with links to ongoing HIV-care centers. - Improve TB screening, diagnosis, and treatment in HIV-infected patients at "HIV" points of entry (CT, PMTCT, etc). - Improve the quality of care for TB/HIV co-infected patients and their families. - Explore the use of preventive INH as part of the national TB program. Through close collaboration with the national programs, the decentralized district health teams, and specialized regional TB and HIV centers, EGPAF plans to realize these COP07 objectives through: - Integration of routine provider-initiated CT coupled with comprehensive care and treatment for both HIV and TB in at least 57 (60%) of the 94 projected national TB DTC sites, with links to ongoing HIV-care sites. At least 7,000 HIV-positive people will receive CT with receipt of results and receive joint HIV and TB care. Training in CT and management of HIV/TB co-infection, as well as related training in planning, supervision, and commodities and data management, will be provided for 120 people. Minor renovation

and medical equipment will be made available to about 10 TB treatment centers currently closed due to the crisis. - Linkages with outreach activities by other EP partners (CBOs/FBOs) targeting family members of TB clients to improve care for HIV/TB co-infected persons and their families; reduce TB- and HIV-related stigma; promote CT, treatment literacy, and adherence; and link clients to comprehensive HIV/TB services. - Integration of standardized clinical TB screening in at least 80% of the EGPAF-supported PMTCT and CT facilities and all 72 HIV treatment sites. TB detection will be integrated in training materials, and at least 250 people will be trained in their use and receive job aids. - Strong joint planning and coordination to increase system-strengthening efforts in M&E (JSI); laboratory (APHL/RETRO-CI); commodities management (SCMS); and human capacity, training, and performance standards (Abt Associates/JHPIEGO/CCP). Ongoing technical assistance will be sought from the USG, WHO, and other experts. Availability of TB commodities will be assured by the national TB program with support from the Global Fund Drug Facility. Human-resources support (on a contractual basis) is anticipated for some underserved zones in light of critical HR gaps. - Completion of a pilot evaluation of secondary INH prophylaxis for TB-HIV infected patients upon completion of their TB therapy. EGPAF will work closely with ISPED/Bordeaux, Measure Evaluation, WHO, and CDC to support the MOH to: a) Integrate HIV/TB indicators into existing tools for TB centers. b) Implement a computerized data-management system. c) Strengthen TB/HIV surveillance at specialized and decentralized TB/HIV centers. d) Improve data flow between the sites and central levels. e) Improve data analysis and use for program management.

EGPAF will train 25 data managers and provide communication tools (fax, Internet), transportation (motorcycles), computers, and accessories. Regional TB centers (CAT) will be responsible for the implementation of M&E activities, and data collected from the TB DTC will be analyzed at the regional level. Lessons learned will be disseminated to improve the quality of services. An annual evaluation and planning workshop will be organized at regional and national levels. Information gathered during these workshops will be used to develop the TB program's annual report, and the upcoming year's district, regional, and national TB/HIV action plan will build upon the lessons learned.

Working in close collaboration with the national TB/HIV control program (joint planning, training of staff, establishment of an efficient drug commodities management system) will strongly contribute to sustainability. EGPAF will provide TA and resources needed to support the TB program in developing advocacy and sensitization campaigns targeting decision-makers, community leaders, health professionals, CBOs, and FBOs to ensure that HIV/TB is a high priority in the allocation of their resources.

The plus up funds will support TB/HIV service integration, identify urgent gaps and needs within the TB lab network, add 10 new TB.HIV sites and enroll 1,320 new TB/HIV co-infected patients, and train more care providers.

This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), HIV/TB (#10057 ), SI (#10074), and Other/Policy & Systems (#10337).

Since 2005, the EP has funded by Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the Ministry of Health (MOH) in supporting and expanding quality HIV counseling and testing (CT) services in Cote d'Ivoire while building on and complementing other programs supported by the EP, Global Fund, UNICEF and others. The EP has supported EGPAF in developing a holistic, family-centered approach to HIV prevention, care, and treatment within the health sector.

The MOH and the USG team have asked EGPAF to support the integration of routine provider-initiated CT as part of comprehensive HIV services at health centers. This program area has the dual goals of detecting patients with HIV in need of care, especially those in need of ARV treatment, and reinforcing provider-delivered behavior-change interventions for primary and secondary prevention of sexual and mother-to-child HIV transmission. This activity complements other EP-supported CT initiatives targeting high-risk populations (sex workers, uniformed services, and truckers/mobile populations) and the general community, especially youth and couples, with outreach to rural and underserved populations and promotion of CT to increase demand and combat stigma in collaboration with PLWHA networks.

All of EGPAF's 57 current service sites support onsite HIV testing. By June 2006, 204 health workers (physicians, nurses, social workers, and lab technicians) at these sites had been trained in CT using trainers and a temporary adapted curriculum developed by the national CT technical working group. A total of 6,658 inpatients and outpatients had received CT, and 3,332 had initiated ART provided by EGPAF. The number tested is an underestimation, because the registries used for data collection at the HIV care centers did not include HIV testing in clinical settings. Less than 5% of supported sites are currently reporting data for CT. Based on this assumption, and counting the 12,451 pregnant women who received their HIV results through PMTCT centers, EGPAF may be on track to reach its projected target of 40,000 persons tested by the end of FY06.

The biggest challenges that EGPAF faced in FY06 were: a) a lack of adapted training materials for CT in clinical settings, b) a lack of integration of CT in clinical-setting indicators in existing tools, c) resistance from TB health-care providers to adopting systematic routine HIV testing, and d) the absence of a CT specialist on the EGPAF technical team. EGPAF is working to address all of these issues. First, EGPAF has started a demonstration project at the university hospital (CHU) in Treichville based on the findings and recommendation of a situational analysis. Second, EGPAF will participate in a national dialogue on the integration of CT in clinical settings into the CT policy, guidelines, and training curriculum. Third, EGPAF will advocate strongly for the evaluation of alternative rapid tests for rural areas without electricity. Finally, EGPAF has begun to recruit a skilled CT expert.

In close collaboration with the national TB control program, FY06 funds are being used to support two new TB centers in Abidjan and one in San Pedro, as well as 13 secondary TB diagnosis and treatment centers. This strategy will result in provision of HAART to at least 300-500 additional TB/HIV co-infected patients per site, since 47% of TB patients are also HIV-infected. Collaborations between CBOs and TB services will be expanded to household level with promotion of adherence, HIV CT, and TB diagnosis for family members. Referrals from the HIV/AIDS Alliance CI, CARE International, and ANADER programs will help identify other adults and children requiring treatment and support. Innovative approaches will be used to reach out to family members of HIV-infected people, building on successful approaches used in CI (Bouake) and Uganda. EGPAF is also on track to integrate CT services in at least three family-planning services in the North (Bouake, Korhogo, and Man) with a new sub-grantee to be identified through a competitive process.

With FY06 funds and based on lessons learned from demonstration sites, new sub-grantees (including health-professional associations) will work to integrate routine HIV testing in all old PMTCT sites in the regions Lagunes, Moyen Comoe, Bas-Sassandra, Agneby, and Haut-Sassandra. Involvement of the health-professional associations will allow rapid documentation of the process and development of simplified CT protocols for

implementation at all non-CHU hospitals where EGPAF is supporting HIV treatment and PMTCT interventions. This will contribute to training 350 health professionals and community counselors and help achieve the goal of providing CT services to 40,000 clients by the end of September 2007.

FY07 funds will permit EGPAF to pursue its district-driven implementation strategy for CT integration, which involves the district team and local CBO/FBOs at all stages, from planning to M&E. CT services will be integrated in primary-level health facilities, large PMTCT service-delivery sites, and family-planning clinics, with functional referral and counter-referral links to available HIV care services in the district, to reach 60,000 clients by March 2008. Priority will be given to hospitals with large inpatient caseloads and access to HIV and TB care and treatment services. In all, EGPAF expects to support 142 CT sites with FY07 funds.

With the expected end of the country's military and civil crisis, special emphasis will be put on resuming interrupted CT services at four major TB centers and, through faith-based and community-run clinics, in a number of underserved districts.

With FY07 funding, EGPAF will work closely with national authorities, the USG team, and the new SCMS program to establish a functional supply chain for CT commodities. EGPAF will also work with the MOH training department, JHPIEGO, professional associations, and NGOs to benefit from their skills and experience in training, supervision, and integration of routine testing in decentralized health services.

Two ongoing structured family-centered approaches in Abengourou and Bouake will be strengthened and documented to feed the national dialogue on revising the national CT policy and guidelines and to produce a replicable model that can be used to expand family-based CT services. In addition, the NGO Renaissance Sante Bouake's home-based CT services in Yamoussoukro appear to be effective in reaching underserved rural populations, and this approach will be documented and expanded to all of Bouaké.

EGPAF-supported sites are being reinforced with improved commodities and data management, in partnership with the SCMS project. EGPAF sites are also boosting their own logistical capabilities through the purchase of necessary equipment (computers, data-management tools, and vehicles for commodities distribution). EGPAF is also complementing the work of the HIV/AIDS Alliance CI, the MOH in partnership with the 20:20 Project, and FHI in building community-level or decentralized capacity, mobilizing resources, and empowering communities to mobilize wraparound resources to improve the sustainability and complementarity of HIV services.

Nutrition support, an important aspect of comprehensive treatment, palliative care, and OVC services, has been less than systematic in many EP-supported programs. Plus-up funds will be used to develop and implement strategies for improving the quality and targeted provision of nutrition support to selected patients receiving ART and palliative care as well as to OVC, pregnant women, and infants of sero-positive mothers.

Strategies will include, as appropriate, infant feeding counseling, support, and follow-up for all HIV-exposed infants and mothers, along with a package of child-survival and reproductive-health interventions with linkages to HIV prevention, treatment, and care services; nutritional assessment, counseling, and support as an integrated part of clinical care and treatment of PLWHA, including routine assessment of anthropometric status, nutrition-related symptoms, and diet, with therapeutic or supplementary feeding support for malnourished patients; linkages to food aid and to social services that can assist in the assessment and support of household food security; necessary training for health workers and OVC caregivers; and wrap-around nutrition support provided as part of home-based palliative care and OVC care. Funded activities will include detailed evaluations and nutritional assessments to define and develop appropriate protocols for patients on ART and pregnant mothers.

This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), HIV/TB (#10057 ), CT (#10062), and Other/Policy & Systems (#10337).

The EGPAF International Family AIDS Initiative comprises programs in PMTCT and in care and treatment. EGPAF's care and treatment program has been growing at an exceptional rate. As of June 2006, 57 comprehensive care and treatment sites had provided ART to 23,698 people, and EGPAF is on track to reach its FY06 goal of 34,200 people on ART at 72 sites.

ACONDA's graduation from main implementing sub-partner to EP prime partner will impact EGPAF's projected targets for FY07, with an initial reduction to 55 EGPAF-supported sites and a treatment cohort of 33,000 PLWA in place of 46,200. However, expansion of sites, partners, and geographic coverage will continue rapidly in 2007, as will growth in "pre-ARV care" cohorts and expanded routine HIV testing and counseling at all supported HIV care facilities.

EGPAF's PMTCT reinforcement and expansion program, started in 2005, has resulted in more than 507 providers trained for PMTCT services, 50,813 pregnant women provided with HIV counseling and testing, and 3,292 HIV-infected pregnant women provided with ARV prophylaxis through 67 PMTCT sites (June 2006). FY06 and FY07 funds will be used to reinforce existing sites (95 by June 2007, with 57,000 women tested) and expand to 120 sites serving 100,000 pregnant women by the end of March 2008.

One of the hallmarks of EGPAF's PMTCT program and care and treatment program (including CT in clinical settings) is the heterogeneity of the sites supported. EGPAF supports many different approaches and models in Côte d'Ivoire. Despite encouraging results, M&E and data management remain a constant challenge for all sites and districts except those supported by ACONDA and CIRBA, which have well-performing computerized data-management tools that keep comprehensive dossiers on all patients (ART or not) registered in the program. Most of the sites currently use national paper tools, including registries. The quality of the data collected suffers from serious constraints, including the following: a) Absence of specific indicators linked to CT in clinical settings b) Absence of indicators related to the longitudinal follow-up of mothers and children from PMTCT c) Lack of standardized patient medical records d) Difficulties in tracking referrals and counter-referrals e) Loss to follow-up because of geographic mobility f) Lack of tools to collect information regarding lab activities related to HIV services g) Insufficient resources allocated to supervision and performance management h) Limited staff dedicated to M&E at district and site levels i) Lack of communication tools (Internet, fax machines) j) Insufficient data flow between sites and the central level and donors

EGPAF is working hard, in collaboration the MOH, JHPIEGO, and Measure Evaluation/JSI, to address these weaknesses through technical and logistic support. EGPAF has provided computers to pharmacies, labs, and districts, with software (from MSH) for drug management and temporary Excel spreadsheets to collect data while waiting for finalization of the standardized approaches to be used in HIV care and PMTCT sites. A training plan related to standards of performance for quality of care is being implemented in partnership with JHPIEGO, which also focuses on formative and post-training supervision. JHPIEGO's Training Information Management System software will be used to manage data related to training. Assessment of the quality of care provided at HIV sites has also begun with TA from EGPAF subcontractor JSI/Boston.

FY07 funds will permit EGPAF to consolidate activities started in 2005 and 2006 to implement timely M&E systems with data use at different levels. The objective is a robust, easy-to-use patient-management system that includes monitoring of drug prescriptions to ensure compliance with national therapeutic guidelines and software that supports quality care and effective monitoring at the individual level.

FY07 activities will train 250 people in strategic information. Activities will include:

1. Provide software and equipment to HIV care and PMTCT sites according to national standards. 2. Provide adequate logistic support related to communication (Internet connection, fax machine, cell phone card), transport (motorbikes), and M&E tools (registries and other materials) at district level, with progressive expansion to sites depending on their size. 3. Procure and install computers and accessories at newly enrolled districts and sites, including new labs, pharmacies, and M&E units. 4. Strengthen Wide Area Network infrastructure at the University Hospital (CHU) of Treichville, with possible extension to Cocody teaching hospital. 5. Promote the use of smart and other patient IDs as a starting point to establish a unique identifier number for a patient or family unit. 6. Initiate a pilot electronic patient-record management system at Treichville university hospital with technical assistance from the University of California-San Francisco, an EGPAF contractor. 7. Build M&E staff capacity at the facility and district levels by training 250 staff members and providing them with essential equipment. 8. Work with other partners and the MOH to develop/adapt software and other M&E and supervision tools/materials to be installed at all EGPAF-supported sites. 9. Perform program evaluations (described in the ARV Services, HIV/TB and PMTCT sections) to improve the quality of services at EGPAF-supported sites.

Smaller sites will use national or WHO-adapted registers; intermediate sites will use software and computers; larger tertiary-level sites will use Wide Area Network infrastructure, including computers and software.

EGPAF will work closely with other key national and international M&E stakeholders within the Ministry of Health (DIPE), the Ministry of the Fight Against AIDS (DPPSE), JSI/Measure Evaluation, and the USG country team, including Projet RETRO-CI. EGPAF contractor ISPED-Bordeaux will be asked to play a greater transversal role in supporting the national data-management system while providing specific technical assistance as needed at district and site levels.

This activity complements EGPAF's activities in ARV Services (#9721, #10068 ), Basic Health Care (#10336 ), HIV/TB (#10057 ), CT (#10062 ), SI (#10074), and Other/Policy & Systems (#10337).

EGPAF is supporting program implementation through a variety of sub-recipients (NGO/CBO/FBO/private sector partners) to provide HIV services in the health sector. These partners have diverse organizational challenges to achieve service delivery goals and meet US reporting requirements due to a lack of experience in HIV/AIDS program implementation and/or weak administrative and financial management systems. Building the technical and organizational capacity of these sub-grantees remains a high priority to build sustainable quality services in Cote d'Ivoire as part of Project HEART.

With FY 06 funds, 20 NGO/FBOs (selected after the first round competitive invitation for concept papers) received initial training on performance based contract concepts and requirements and further extensive technical assistance was provided to the first 6 awardees to develop budgeted proposal consistent with USG rules and regulation. With FY 07 funds, EGPAF will coordinate with other EP partners involved in sub-granting and support: • Assessment of the capacity building and organizational strengthening needs for the 6 1st round awardees and subsequent awardees selected through subsequent rounds (anticipated 10-20 total) • Orientation and training workshops for the administrative and management senior staff of targeted health professional associations (SIPE, SIPIT, SOGOCI, SIP, GROFORMED) to reinforce their administrative, financial and program management capacities in support of their organisation's role in network development, training and service delivery • 3 thematic workshops on USG funds management for its sub-grantees with training in specific technical areas such as proposal development, strategic planning, and monitoring & evaluation for health programs EGPAF human resource skills capacity development will complement those of other EP partners including ACONDA, Abt Associates and JHPIEGO and focus on: • Technical and logistic support to 2 HIV specialist adult and pediatric care centers to establish a valuable mentorship and preceptorship training program in collaboration with the Faculty of medicine and University of California San Francisco • Contracting the initial and continuing training of HIV/AIDS care providers at EGPAF supported sites through interested health professional bodies. • Partner with preservice training institutions (medicine, pharmacist, social worker; nurse and midwives, lab technician) to provide short time residential internship to students finishing their studies to create a pool of young and new expertise in the field of HIV/AIDS • Collaborate with MOH to capture all training activities supported by EGPAF in the Training Information Management System • Develop a plan/program for the placement of trained providers in selected service delivery sites • Monitor and document performance of these providers These activities complements the day-to-day support provide to the recipients and contributes to the sustainability of EGPAF supported programs.