With FY08 funds, USG technical staff will continue to work closely with program management staff and HQ

technical staff to provide technical assistance for the design, implementation, and evaluation of PEPFAR-

funded interventions aimed at preventing mother-to-child HIV transmission. These activities are conducted

in consultation with relevant ministries (Family and Social Affairs, Health, Fight Against AIDS), non-

governmental organizations, multinationals, and bilateral organizations.

Ongoing specific activities will include:

1. Supporting the implementation and coordination of PMTCT activities among donors and partners (e.g.

UNICEF, UNAIDS, UNDP, and PEPFAR-funded partners including EGPAF, ACONDA-VS, Columbia-ICAP,

and technical ministries)

2. Providing laboratory support at Projet RETRO-CI for quality point-of-service HIV testing with quality

assurance at PMTCT sites, purchasing of laboratory commodities and supplies, training of peripheral-site

staff, supervision, and quality-assurance services

3. Participating in the PMTCT working group and assisting the MOH to develop innovative approaches for

rapid scale-up, including:

• A district approach with strengthening of PMTCT monitoring and evaluation at the district and site levels, in

collaboration with RETRO-CI/SI, Measure, DIPE, and other key partners

• Early infant HIV diagnosis by PCR, in collaboration with RETRO-CI/Lab and CDC HQ

• Routine HIV counseling and testing in ANC services

• Rapid testing in labor-and-delivery services

• Linkages with care and treatment

4. Providing technical assistance to the MOH and national experts to complete the validation, dissemination,

and regular updating of PMTCT policies and guidelines, with anticipated revisions related to couples

counseling, HIV testing algorithms, infant feeding, and reaching women during and after labor

5. Establishing a formal monthly discussion involving EGPAF, ACONDA-VS. Columbia-ICAP, the

CDC/USAID country team, JHPIEGO, and other key partners to follow PMTCT activities, focusing on major

points such as commodities management at the central and the district levels, longitudinal postnatal follow-

up of mother/infant and linkages with pediatric care, and coordination with other partners (UNICEF, PATH,

HIV/AIDS Alliance, UNFPA, WFP, ANADER, Care International, and PLWHA)

6. Assisting EGPAF, ACONDA-VS, and Columbia-ICAP to develop new partnerships with the public and

private sectors, FBOs, and CBOs to expand PMTCT activities nationwide

This funding represents a percentage of Alliance CI 's OP funds reprogrammed to CDC HQ to support

adaptation and translation of culturally appropriate HIV prevention for positive tools and materials which will

be disseminated to all clincal facilities implementing a comprehensive care and treatment program.

With fiscal year 2008 funds, the USG CI team will provide direct technical assistance to the Government of

Cote d'Ivoire and to our implementing partners, supplemented by targeted assistance from CDC

headquarters, in support of the country program in the following areas: sexual prevention for positives, at

risk, and highly vulnerable populations, such as professional and transactional sex workers, uniformed

services and ex-combatants, truckers, and prisoners. USG CI will support the in-country travel and logistics

for all USG CI TA and TA requested from HQ.

With FY08 funds, the USG CI team will provide direct technical assistance to the government of Cote

d'Ivoire and to our implementing partners, supplemented by targeted assistance from CDC headquarters, in

support of the country's palliative care program. USG CI will support in-country travel and logistics for all

USG CI TA and TA requested from HQ.

In the area of palliative care, the country team will provide ongoing technical assistance, augmented by

technical assistance from CDC HQ staff, to support the integration and scale-up of prevention, diagnosis

and treatment for OIs, including TB, malaria, and STIs; provision and distribution of cotrimoxazole for all HIV

-positive patients who qualify according to national guidelines; basic pain management; insecticide-treated

bed nets; interventions to improve hygiene and water safety; and psychosocial support.

With FY08 funds, USG technical staff will continue to work closely with the interagency country

management team and HQ technical staff to provide technical assistance and coordination for EP-

supported activities aimed at improving the lives of orphans and other vulnerable children (OVC) and

families affected by HIV/AIDS. USG technical staff assists the host government and nongovernmental

organizations with ongoing implementation and coordination of OVC-related activities.

These efforts are conducted in consultation with the Ministry for the Fight Against AIDS, other technical

ministries (Education, Health, Family and Social Affairs, Human Rights), multinationals, bilateral

organizations (UNICEF and other UN agencies), and EP-funded partners such as FHI, HIV/AIDS Alliance,

CARE International, ANADER, and JHPIEGO.

USG technical staff contributes to the development and implementation of policies and programs pertaining

to OVC populations and ensures the ongoing development of programs to improve delivery systems of the

public health sector of Cote d'Ivoire. USG staff provides technical support to partners to expand quality

services for OVC and their families and provides technical assistance in program design, supervision, and

monitoring and evaluation of EP-supported OVC activities.

With FY07 funds, Projet RETRO-CI, the CDC-MOH collaborative USG-funded project, will continue its

support to the tiered MOH national public health laboratory system and will reinforce the institutional

capacity and the coordination role of the national HIV, TB, and malaria programs in building sustainable

national infrastructure, managerial and technical workforce capacity and expanding services to provide

quality diagnostic testing, clinical laboratory monitoring of treatment, and surveillance.

While building capacity at the national reference laboratories, RETRO-CI will continue to provide HIV

reference testing and quality assurance to support quality services within the national laboratory network. A

major and expanding activity is the progressive transfer of competence and technologies to the designated

national reference laboratories to provide the minimum package of HIV laboratory services at all levels

nationwide. RETRO-CI's technical assistance will support achievement of both PEPFAR country goals and

national strategic plan goals. In support of the effort to scale up HIV testing, RETRO-CI will complete the

assessment and operationalization of a simplified rapid HIV testing algorithm and the assessment and

operationalization of the new CDC Rapid HIV Testing Logbook. In support of the scale-up of early infant

diagnosis, RETRO-CI will provide DNA PCR services for conventional and DBS whole-blood specimens.

RETRO-CI will continue to support the laboratory component of strategic information activities, including

HIV testing and analysis of the 2007 national antenatal sero-prevalence survey and sentinel surveillance of

transmitted and emerging HIV drug resistance as part of the treatment program evaluation. These activities

will be implemented in collaboration with the MOH national HIV and TB programs (PNPEC and PNLT), the

national reference laboratory (LNSP), the national TB reference laboratory (Institute Pasteur CI), the UFR of

Pharmacy and Medicine, the national training institution of health care workers (INFAS), the National Blood

Bank, the WHO, HHS/CDC/HQ, CDC international laboratory cooperative agreement partners, and all

relevant PEPFAR implementing partners and stakeholders.

In FY08, activities will be based on lessons learned from the implementation of FY07 activities. A principal

activity will be the collaborative development of a five-year strategic laboratory plan that will serve as the

basis for the development of a sustainable national laboratory system. In addition, RETRO-CI will

concentrate on the following priority activities in an effort to scale up quality lab services supporting HIV

prevention, care, and treatment programs:

Support of laboratory networks and integrated laboratory services by:

1. Supporting the rapid scale-up of HIV testing services to improve access at CT, PMTCT, TB/HIV, and care

and treatment sites throughout the country. This support will consist of:

- Implementing at all PEPFAR-supported medical and non-medical sites simplified whole-blood finger-prick-

based rapid-testing algorithms

- Assessing the proficiency of non-laboratory professionals (nurses, midwives, lay counselors) to perform

HIV rapid-testing algorithms and related QA activities

- Providing recommendations for any changes needed in the national HIV testing policy based on these

assessments

2. Supporting expansion to access of biological monitoring for patients on ART at all levels by conducting

and promoting field validation of simple technologies at the point of care where appropriate

3. Supporting the MOH by creating a specimen referral system from sites without laboratories to regional

laboratories. This will include a system for the timely reporting of site laboratory results to the reference

laboratory

4. Implement the logbook for HIV rapid testing developed by CDC at all HIV testing sites to standardize

reporting of results.

5. Providing TA for the roll-out of early diagnosis of HIV infection in HIV-exposed infants at 6 weeks-12

months (at least 6 weeks after cessation of breastfeeding) by DNA PCR using dried blood spot specimens

at all PMTCT sites and immunization clinics. This will be achieved by:

- Transferring DNA PCR technology using DBS to three central laboratories (CeDreS, IPCI, CIRBA)

- Providing test kits and supplies for testing up to 10,000 HIV-exposed infants

- Collaborating with the MOH to review and change policies on early infant diagnosis to reduce the need for

costly DNA PCR testing by performing early HIV rapid testing on infants before 12 months.

6. Provide TA to build appropriate reference testing capabilities and facilities within the LNSP. This will

include providing assistance for the coordination of an external quality assessment program for HIV

serology in collaboration with ASCP for the development of a laboratory quality system.

7. Providing TA to the national TB program for the provision of HIV CT at all TB centers. This will include

training of CAT and CDT staff on HIV testing and QA/QC and training and coaching of TB supervisors for on

-site supervision of CT services.

8. Supporting ART clinical laboratory monitoring for HIV-infected patients at the infectious diseases

department (SMIT) and outpatient clinic (USAC) of the university teaching hospital of Treichville, Mèdecins

Sans Frontières (MSF), and other treatment sites according to national guidelines by providing lab services

for: full blood count (FBC), CD4 + T-cell count, full chemistry including but not restricted to liver enzymes

(transaminases), renal function test (creatinine), glucose, lipids, amylase and serum electrolytes, HIV RNA

viral load, Hepatitis B and C virus serology.

Technical assistance in laboratory quality assurance by:

1. Monitoring the performance of laboratory sites for the accuracy of HIV testing and ART clinical laboratory

monitoring:

- Continue TA for an initial assessment of laboratory staff at new PEPFAR-supported sites and periodic on-

site supervision at all sites with progressive transfer of competencies to the regional and district levels

- Organize an external quality assurance (EQA) program for HIV serology through a two-year cooperative

agreement with the national reference laboratory (LNSP)

- Support the EQA/PT program for CD4 testing in collaboration with LNSP and CeDReS

- Identify, with LNSP, and support a suitable partner to establish and pilot a QA program (including

EQA/PT) for hematology and clinical chemistry

2. Transferring competencies for and decentralizing supervision of HIV testing sites to regional supervisors

by creating a national pool of supervisors; implementing a national guide for supervision, related

standardized supervision forms, and checklists

3. Providing TA to develop the overall QA program, including but not limited to the definition of QA

standards for all laboratory categories.

Activity Narrative: Provide training by:

1. Continuing to support the improvement of pre-service training institutions, including updating curricula,

provision of lab equipment and supplies, and training of staff

2. Continuing to support the national HIV and TB programs for in-service trainings (HIV and CD4 testing,

laboratory quality management, and maintenance of basic equipment)

3. Supporting the implementation and rollout of standardized training materials, including the

comprehensive WHO/CDC HIV rapid-testing training package and the WHO/CDC/IUATLD/APHL/RIT direct

TB smear microscopy training package.

Additional activities:

RETRO-CI will:

1. Continue to support the lab component of strategic information activities, including evaluating the national

care and treatment program for emerging ARV drug resistance in patients at 12 months of treatment to

assess the effectiveness of current ARV drug regimens

2. Implement a threshold survey for transmitted drug resistance among pregnant women at selected ANC

sites

3. Validate new HIV incidence surveys and targeted evaluation studies to:

- Validate simple and easy-to-use new technologies for CD4 testing +/- complete blood count (Auricare

NOW, FACSCount CD4Abs/CD4%) to evaluate their appropriateness in laboratory programs.

- Validate rapid nucleic acid technologies for quantification of viral load (real time PCR)

- Assess the feasibility of new methodologies (dried tube serum) for EQA for HIV serology.

- Assess the suitability of newly available commercial cell stabilizers for CD4 count and full blood count

- Assess the residual risk of window-period HIV infections using nucleic acid techniques (NAT) and pooling

strategies (cross-referenced CNTS mechanism 4933)

4. Apply to be a WHO regional HIV Drug Resistance Collaborative Center. This will enable RETRO-CI to

provide TA to other PEPFAR and regional countries with limited resources for implementing drug-resistance

surveillance

5. Collaborate with ASCP and CLSI in evaluating, developing, improving, and maintaining their laboratory

quality management system (managerial and technical) in compliance with CAP and ISO 15189

requirements with the goal of accreditation. This will be two- to three-year process. RETRO-CI will serve as

an advisory body for supporting the accreditation of national and regional laboratories, thus evolving its role

at the national and regional level as a center of excellence for training and QA.

6. Collaborate with the National Public Pharmacy (PSP), the Supply Chain Management System (SCMS),

and PEPFAR implementing partners to improve the supply-chain system

7. Provide TA for training of staff on inventory and stock management.

Laboratory commodities and equipment will be purchased directly and are projected to total $1,526,765;

staff salaries and administrative costs to support 26 RETRO-CI laboratory affiliated positions make up the

balance.

With significant Emergency Plan financial and technical support, the government of Cote d'Ivoire is

improving national capacity to respond to the HIV/AIDS epidemic throughout the country. In the realm of

strategic information, the primary technical contribution of the USG is implemented by the strategic

information staff of Project RETRO-CI, which is a collaborative organization created jointly by the Ministry of

Health (MOH) and the CDC. RETRO-CI is a critical partner in the development of the Three Ones principle

of a unified national monitoring and evaluation system promoting coherent health management information

systems (HMIS) and HIV/AIDS surveillance.

During the past three years, the RETRO-CI SI team has assisted EP partners to develop, implement, and

coordinate comprehensive SI activities providing key data for decision-making in the fight against HIV/AIDS.

RETRO-CI continues to provide HMIS and surveillance assistance to the Ministry of Health (MOH) and the

Ministry for the Fight Against AIDS (MLS), including support for the development of a nationwide

harmonized longitudinal patient-monitoring system. RETRO-CI has conducted annual ANC HIV surveillance

surveys and helped conduct the 2005 National AIDS Indicator Survey. In addition, the RETRO-CI SI team

has participated, under the coordination of JSI/Measure Evaluation, in the harmonization of national

HIV/AIDS indicators and the development of national data-collection tools for the tracking of facility-based

and community-based activities.

With FY08 funds, the SI branch at RETRO-CI will continue to provide technical assistance to support the

building and strengthening of a unified national M&E system and the conversion of HIV/AIDS data to useful

information through the three components of strategic information — monitoring and evaluation, health

management information systems, and surveillance.

Monitoring and Evaluation

RETRO-CI SI M&E activities will aim to collect and aggregate data to provide information to support the

management of the EP program in Cote d'Ivoire. RETRO-CI has developed an SI strategy for PEPFAR

Cote d'Ivoire and will provide technical assistance to EP-funded implementing partners to ensure that they

have the capacity to meet EP reporting requirements and to use data effectively for program improvement.

This activity will include the provision of French-language SI materials and training, the preparation of

reports aggregating program data of EP implementing partners, and the presentation of written and oral

reports to national partners and stakeholders. The USG will also begin the data-quality audit (DQA)

process, including onsite supervision and partner-performance evaluation.

HMIS

The national M&E system lacks expertise in health information systems. The RETRO-CI SI team will

provide continued technical assistance to the MLS, the MOH, the Ministry of Education, the Ministry of

Family and Social Affairs, and other EP partners to implement a fully functional M&E system that will

improve routine data reporting and data use. This will include support for revision, dissemination, and

implementation of national strategies in strategic information. With CDC HQ technical assistance, Project

RETRO-CI will assist in:

- Implementing a national-scale ART patient-monitoring system using adapted WHO ART patient-monitoring

forms and an electronic ART monitoring tool.

- Designing or adapting software, databases, and computer applications that support specific HIV/AIDS

program activities (CT, PMTCT, OVC, etc.).

- Designing a national data repository on HIV/AIDS. This secure data repository will respect WHO privacy

and confidentiality guidelines and will aim to be a one-stop provider of HIV/AIDS data at the individual and

aggregate levels.

- Supporting ongoing adaptation and scaling up of the national-level Training Information and Management

System (TIMS) software to track the coverage of human resources providing HIV/AIDS-related services

- Addressing confidentiality, privacy, and security in the management of data related to HIV-infected

individuals. This will include the development of a national unique identifier.

- Promoting the use of data for decision-making by using data visualization and building GIS core

competencies that address EP and national needs.

- Improving HIV-related data quality and use by developing national policies and guidelines, by training

government and implementing partner personnel, and by supervising data collection and management

activities.

- Providing all EP-funded partners with data-management software (MESI) for data storage and decision-

making, with Solutions technical assistance.

In addition, the RETRO-CI SI team will provide support in informatics to a variety of government actors,

NGOs, and other organizations. Specific activities will include:

- Training in the use of data-management and statistical software packages, such as Epi Info, CRIS, MESI,

and PMS.

- Assisting the MOH with its next-generation national health management information system, which

integrates HIV indicators with other health-outcome measures.

- Assisting with the development and implementation of a national M&E system while supporting the

achievement of EP prevention, care, and treatment goals. This assistance will include the translation of

software programs and training materials, supervision, and development of quality-assurance guidelines.

- Working with the national SI technical working group to develop recommendations for facilitating the

integration of data collection in the field, with the aim of reinforcing linkages between different HIV-related

services. This technical assistance will complement SI activities funded through cooperative agreements

with the MLS, the MOH, and other partners in support of creating a functional national M&E system.

Surveillance and Surveys

For the past two decades, RETRO-CI surveillance activities have been the main source of country-level

HIV/AIDS data in Cote d'Ivoire. Within the framework of knowledge transfer to the host government,

RETRO-CI will support the MOH and MLS (ministries in charge of the country's HIV/AIDS surveillance

system) and other EP partners by:

1. Providing technical and logistical assistance to the MOH to support the development and execution of a

dissemination plan for the 2007 national antenatal HIV surveillance survey (ANS). With FY07 funds, 100

health personnel were trained, blood samples were collected at 30 urban and 12 rural sites and tested at

Project RETRO-CI's laboratory, and data was entered into a database.

Activity Narrative: 2. Informing programmatic decision-making by conducting further analyses of available surveillance and

program data (CT, PMTCT, ART) through a data-triangulation exercise, with the aim of describing the

patterns that drive the HIV epidemic in Cote d'Ivoire as well as the impact of the national response.

Technical assistance for protocol development and implementation will be provided by CDC headquarters.

3. Providing technical and logistical assistance to the MLS to carry out a population-based HIV survey

(either a Behavioral Surveillance Survey or a Demographic and Health Survey) to assess the impact of

prevention, care, and treatment interventions. Assistance will support sample collection for anonymous HIV

testing at selected sites, transport of samples, testing at the RETRO-CI laboratory, data management and

analysis, a written report, and dissemination of the results through a variety of media (paper reports, CD-

ROM, Web site).

4. Providing technical and logistical assistance to the MOH and to Abt Associates, in collaboration with the

WHO and other partners, to complete dissemination of the findings of a recent service provision

assessment (SPA) through a workshop, training, written reports, and a CD-ROM (started in FY07).

5. Providing technical assistance as needed to support a variety of in-country partners with the

implementation of public health evaluations (PHEs) and targeted evaluations. Assistance will include

support for the evaluation of HIV drug resistance, the investigation of recent HIV infections, and the

evaluation of nutrition and food support strategies (breastfeeding, OVC food support, nutrition as part of

palliative care). RETRO-CI will procure laboratory and study supplies, collect samples at peripheral sites,

transport specimens for testing at the RETRO-CI laboratory, manage and analyze data, and disseminate

results through a communication plan. Technical assistance will be sought from CDC HQ for conducting

initial assessments, developing protocols and guidelines, and planning activities.

Regional Support

RETRO-CI will collaborate with other francophone African countries to support the development of their

strategic information capacities. Building on two decades' experience in SI (including translation into French

of Epi Info and TIMS software), RETRO-CI continues to manage data related to tens of thousand of patients

that has supported the publication of more than 300 peer-reviewed articles. RETRO-CI will take advantage

of this extensive experience to assist other francophone countries by:

1- Organizing regional SI workshops and trainings in French.

2- Supporting the development and implementation of health information systems in French.

3- Providing French-speaking experts to other countries for technical assistance in strategic information.

Despite the cost containment measures on the part of ICASS management as well as agency-specific

efforts, Cote d'Ivoire has one of the highest ICASS costs in the African Region. This is partly due to the high

cost of doing business in Abidjan, Cote d'Ivoire and the expense of operating a newly constructed embassy

compound inaugurated in 2005. The operating costs of the new Embassy have increased due to building

construction failures and the cost of fuel to run two generators to produce electricity rather than running

directly off the national power grid. The need to generate power on site using diesel generators was

necessitated by the frequent power surges placed sensitive embassy communications and other equipment

at risk. To offset the increased costs of operating the embassy, there was a reduction in force of 12 LES this

year, along with other cost saving measures.

Although Cote d'Ivoire is emerging from a lengthy politico-military crisis, agencies at post remain

significantly downsized. CDC is one of the few agencies that has remained and bears a significant burden

of the cost sharing of operating one of the largest embassies in West Africa, as well as paying for the actual

space in the embassy used in support of the interagency PEPFAR team.

Along with growth in the PEPFAR program in Cote d'Ivoire, the CDC portion of ICASS costs will increase as

a direct result of the need for increased office space (and workstations) at the NEC, as well as increasing

demands in support of the PEPFAR program for Embassy services with associated ICASS charges.

$1,400,000 is projected for total ICASS charges for FY08. The ICASS services which are used frequently

include HR processing, procurement, contracts, financial and other activities needed to support the

interagency PEPFAR program at post.

OBO costs in FY07 were paid from country budget allocations and this will continue in FY 08. The OBO

charges (projected to be $280,000 in FY08) apply to the total number of existing authorized positions for

each US agency including both filled and vacant positions (includes all "persons" employed by the agency,

FTEs, LES, PSCs and temporary appointees). The fully integrated interagency PEPFAR staff currently

numbers 91, including 23 staff associated with the RETRO-CI laboratory; and the team anticipates hiring 15

additional staff in FY08. The OBO charges are rated per person and based on the type of office space

allocated to each position. Currently, CDC supports the PEPFAR coordinator, the USAID focal point and

four members of its management and support staff in the NEC space. The majority of PEPFAR staff will

continue to be located at the Ministry of Health/RETRO-CI site in Treichville. However, office space there is

currently at capacity and expansion at this site is not an option due to limitations on construction authority

for CDC. With the available space at the embassy, the interagency team will plan to locate 8-10 additional

staff at the embassy in FY08.

As CDC overseas operations have rapidly expanded, CDC HQ has found it difficult to keep up with the need

to provide support to the field. Support for PEPFAR-CI Information Technology requirements continue to be

challenging in country as a result of satellite limitations, electrical power outages, and a growing need to

offer IT support to increased staff without an increase in IT support staff. In a much needed effort to address

the growing IT needs for CDC operations overseas, in FY08 the CDC HQ based Information Technology

Services Office (ITSO) will establish an annual support cost of $3250 dollars per workstation and laptop at

each location [projected to be $341,250 for the PEPFAR Cote d'Ivoire interagency program] to cover the

cost of Information Technology Infrastructure Services and Support provided by HQ. This cost will include

funding to provide a base level of connectivity for the primary CDC office located in each country to the

CDC Global Network, keeping the IT equipment located at these offices refreshed or updated on a regular 3

-4 year cycle, financial resources for expanding the ITSO Global Activities Team in Atlanta as well as fully

implementing the ITSO Regional Technology Services Executives in the field. This is a structured cost

model that represents what is considered as the "cost of doing business" for each location.