The goal of John Snow International's Making Medical Injections Safer (MMIS) project is to build the

capacity of the government of Cote d'Ivoire to prevent the transmission of HIV and other blood-borne

diseases by improving the safety of medical injections. Despite remaining effects of Côte d'Ivoire's five-year

crisis, including severe disruptions in the national health system, MMIS now conducts safe-injection

activities in 45 health districts (63% of all health districts). The program benefits from a collaborative work

environment with local partners and responsive technical support from MMIS-Washington as well as USG

technical staff. MMIS works in collaboration with WHO, UNICEF, and other partners to complement and

support safe-injection activities implemented by the Ministry of Health (MSHP).

MMIS' approach focuses on building local ownership and sustainability of injection safety and waste

management (ISWM) activities. In 2008, MMIS is expanding to nine more districts in areas formerly under

rebel control in the North, West, and center of the country, and is supporting:

Capacity Building: 2,824 health workers and waste handlers were trained in ISWM practices from March to

September 2008 in 15 health districts, one teaching hospital, and one private-sector institution. A total of

8,049 persons have been trained from October 2004 to September 2008.

Logistics Management: 45 districts are being regularly supplied with safety syringes (auto-disable and

retractable) and safety boxes. The program works through the MSHP Supplies Distribution Network, which

is managed by the National Public Health Pharmacy (PSP).

Behavior Change Communication: Job aids and other communication aids for health care workers were

produced, tested, and disseminated in all program intervention districts. Field visits were conducted in

intervention districts to promote behavior change among health workers and to advocate for resources for

building incinerators. Discussions and sensitization sessions were organized for media professionals and

leaders of health worker associations. Radio and TV messages for behavior change in communities were

developed and tested.

Waste Management: MMIS assisted the MSHP in updating the 2009-2011 National Waste Management

Strategic Plan. The project also supported two intervention districts in repairing incinerators.

Monitoring and Evaluation: Supervision visits were conducted with central and district-level supervisors in

intervention districts, focusing on key programmatic indicators.

Activities planned with FY09 funding are consistent with MMIS' 2005-2009 Strategic Plan. With limited

funding as the project approaches its end (September 2009), MMIS will be able to operate at approximately

a 60%-75% activity level. The MMIS-Cote d'Ivoire team is committed to working closely with the PEPFAR

country team and the MSHP to define priority activities in each technical area and review the ongoing

technical support that MMIS provides to in-country partners to assure a smooth transition to MSHP

leadership of injection-safety activities.

With FY09 funding, MMIS expects to expand to nationwide coverage and build on the project's successes

by reaching 15 additional districts and one teaching hospital. MMIS plans to implement interventions that

will continue beyond the life of the project, focusing on coordinating activities with key injection-safety

partners at the national, district, and local levels, while supporting the transition of activities to the MSHP.

Collaboration with other PEPFAR partners remains a priority and will be achieved through regular meetings

and ongoing communication.

In training and capacity building, MMIS will focus on training 60 district-level trainers and 1,400 health care

workers. MMIS will provide support to each of the 15 new districts and the teaching hospital of Cocody in

elaborating integrated injection safety and health care waste management plans. These plans will stipulate

all injection-safety interventions to be implemented in each district, including staff training. MMIS will equip

trainers with training materials, including trainer's handbooks, to facilitate continuous training in the long

term.

MMIS will continue to work with the Directorate of Nursing and directors of the various medical training

institutions to revise training curricula to include injection-safety concepts, including phlebotomy and post-

exposure prophylaxis (PEP) procedures. An orientation manual will be elaborated to cover the needs of new

health care workers recruited after injection-safety training has taken place in their facilities.

To reinforce training efforts and strengthen the capacity of providers to administer only safe and necessary

injections, joint supportive supervision visits will be conducted with the MSHP, PEPFAR country team, and

district authorities using MMIS-developed supervision checklists. This activity will have the added benefit of

training supervisory authorities on using indicators in monitoring injection safety and health care waste

management. MMIS will advocate with the MSHP to integrate these indicators into the national health

management information system (HMIS) as well as with the PEPFAR country team to develop an integrated

checklist that includes injection safety-related indicators for all PEPFAR-supported projects.

As part of MMIS' transition plan for procurement and commodities management, the project will release all

stocks of injection-safety commodities to PSP and the districts, maintaining remote monitoring of both the

distribution and management of these stocks. Results of a feasibility study that PSP will conduct will be

critical in promoting the continued use of syringes with re-use prevention features as well as the utilization

of safety boxes. MMIS will continue to support the PSP in the analysis and development of strategies

resulting from the study. As stipulated by the revised MOU signed by the PSP and MMIS-Côte d'Ivoire, the

PSP will assume responsibility for training health care workers and building the capacity of district pharmacy

managers to effectively use the logistics information management system to ensure that adequate injection

supplies are available at service delivery points. Since a significant portion of injection devices in the

country are provided through the private sector, MMIS will engage private-sector importers through targeted

advocacy and sensitization.

Behavior change communication (BCC) and advocacy efforts will contribute heavily to MMIS' work in the

expansion districts. The project will also continue to reproduce and distribute existing BCC materials and job

aids to reinforce injection-safety messages in earlier intervention districts. To complement facility-based

interventions, a nationwide multimedia campaign will focus on changing community members' attitudes

Activity Narrative: toward injection safety in the expansion districts. MMIS will also work with the health communications unit of

the MSHP and with district authorities to create district communications teams that will be equipped with

materials to guide BCC and outreach strategies within the districts. Targeted communication will also be

directed toward health professional associations and unions.

Health care waste management efforts during this period will focus on advocacy with the government and

other partners in the health sector for resources for additional incinerators. Results of a pilot project on

health care waste management in large hospitals conducted in Port-Bouët and Alépé will be used to

develop interventions in one teaching hospital (CHU Treichville) while MMIS continues technical assistance

to experimental hospitals. MMIS will continue to provide personal protective equipment (PPE) to waste

handlers while advocating for the inclusion of a budget line at all health facilities for health care waste

management to ensure sustainability in this area.

To bolster advocacy efforts to protect health worker safety, MMIS will support the MSHP in conducting a

national workshop to develop and harmonize strategies to manage occupational exposure to blood and

biological fluids, including needle-stick injuries. Advocacy for systematic vaccination of health workers

against hepatitis B will also continue. Joint supervision visits are planned to monitor the use of PPE and job

aids that reinforce training elements.

With respect to phlebotomy, MMIS will finalize a situational analysis of phlebotomy practices in the country

and will use the results to support the MSHP and other partners in developing effective strategies to

implement safety measures in this area.

To ensure continuous monitoring and evaluation of activities in this last year of the project, particularly with

respect to sustainability strategies, injection-safety taskforce meetings will focus on assessing transition

strategies and reflections on the way forward. Quarterly supervision activities with PEPFAR partners will be

leveraged to further promote norms and standards related to improved injection practices, while monthly

meetings with the PEPFAR country team will be used to fine-tune phase-out strategies. Finally, a

stakeholders' review of the project will provide an opportunity to assess achievements as well as elaborate

a five-year strategic ISWM plan that will also address issues such as sustainability, quality assurance, and

an ISWM standard package of interventions.

Overview of transitional issues and sustainability strategies

Training and supervision: Strategies for sustainability of MMIS activities in the area of training include both

in-service and pre-service training. For in-service training, efforts will focus on training of trainers at central

and district levels. Pools of trainers, including trainers from the PSP, will be supplied with operational

manuals to enable them to continue training on ISWM. Building partnerships with national health programs

(i.e. malaria, reproductive health, the National HIV/AIDS Care and Treatment Program (PNPEC)) and other

PEPFAR partners to integrate ISWM in their existing training programs and modules will also play a major

role in the sustainability of in-service training.

Integration of ISWM in pre-service training institutions started with the National Institute of Health Worker

Training (INFAS) and will be expanded to other pre-service training institutions (for physicians, pharmacists,

and dentists).

Although field supervision remains irregular within the national health system, integration of key ISWM items

in a district-level supervision checklist is the most relevant way to sustain MMIS supervision activities.

Procurement and logistics: Globally, logistic and procurement activities implemented under JSI/MMIS will

be carried on with SCMS through a close partnership with the MSHP and PSP. The introduction of safety

devices (auto-disable syringes, retractable syringes, and safety boxes in the public-sector curative-care

system through the PEPFAR injection-safety project) has greatly helped in tackling issues such as the

reuse of needles and syringes, accidental needle-stick injuries, and the improvement of sharps-waste

management. As a result, the MSHP and PSP have decided to continue supplying health facilities with

these devices, particularly safety boxes. In order to sustain the procurement and distribution of safety

supplies after MMIS, a feasibility study by the PSP is expected to draw scenarios on logistics, market, and

financial issues that will inform MSHP decision making. Regarding the private sector, advocacy toward

private importers and distributors will continue for the promotion of safety devices (especially safety boxes)

and their integration into the private-sector procurement and distribution network under the leadership of the

national MSHP regulatory authority, the Direction of Pharmacy and Medication.

BCC: BCC and advocacy activities implemented under JSI/MMIS target health workers, patients, and health

system managers, as well as the general population. These interventions will be maintained by reinforcing

the commitment of media, local NGOs, and health professional labor associations. At the district level, focal

points for communication should continuously be informed and refreshed on ISWM issues that are being

integrated.

Health care waste management: Sustainability of waste management interventions - particularly the use of

safety boxes, whose introduction and broad use in curative-care sector is one of the major

accomplishments of MMIS - will be possible through continued procurement and distribution by the PSP

with the support of SCMS. In the long term, the purchase of safety boxes from local manufacturers, as a

result of ongoing advocacy for manufacturing by local enterprises, will contribute greatly to sustainability

efforts. The waste-segregation system that has been successfully experimented in two hospitals should

continue and progressively expand to other health facilities under the leadership of the General Direction of

Public Hygiene (DGHP). Construction of incinerators for proper final destruction of health waste remains a

great challenge that could be addressed by joint efforts from all partners: MSHP, WHO, Global Fund,

UNICEF/GAVI, World Bank (MAP project), local government entities (conseils généraux), and municipal

governments (mairies), under the strong leadership of the DGHP.

Health care worker safety and safe phlebotomy practices: Reinforcement of health care worker safety,

Activity Narrative: including promotion of hepatitis B immunization, surveillance of accidental needle-stick injuries, advocacy

for the provision of PEP, and the improvement of safe phlebotomy practices in laboratories, are among

JSI/MMIS activities to be maintained and/or further developed. Sustainability of interventions in these sub-

areas will require the leadership of the MSHP operational program (the PNPEC) in liaison with other

partners, such as health professional labor associations, national and international organizations addressing

occupational health issues, the National Public Health Laboratory, and the CDC/Retro-CI laboratory.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15132

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

15132 10194.08 HHS/Centers for John Snow, Inc. 7054 4932.08 JSI Injection $2,412,646

Disease Control & Safety

Prevention

10194 10194.07 HHS/Centers for John Snow, Inc. 4932 4932.07 JSI Injection $0

Disease Control & Safety

Prevention

Emphasis Areas

Construction/Renovation

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $134,829

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $6,450,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Background

Côte d'Ivoire's adult HIV prevalence is estimated at 3.9% (UNAIDS 2008). The most recent National AIDS Indicator Survey (2005)

showed that the epidemic is marked by important gender and geographic differences. Females in all age groups are more likely

than males to be infected with HIV (6.4% vs. 2.9% overall, 14.9% vs. 5.6% among ages 30-34). Prevalence is marginally higher in

urban vs. rural settings and markedly higher in the South and East (5.5% or higher) than in the Northwest (1.7%). Access to and

uptake of PMTCT and CT services are low. Only 11% of women and 8% of men report ever having had an HIV test, and only 7%

of women access PMTCT services during antenatal care (AIS 2005). Among an estimated 420,000 adults living with HIV/AIDS,

about 190,000 are estimated to be in need of ART (UNAIDS 2008).

Within the context of a country moving toward stability but limited by poorly equipped, critically understaffed health and social

services, the USG program is working to build a continuum of comprehensive HIV/AIDS prevention, care, and treatment services.

Care and support services are delivered at 240 health facilities (September 2008), as well as through community- and home-

based caregivers, mobile services, and organizations targeting high-risk populations, such as teachers, the uniformed services,

and commercial sex workers. Between October 2007 and September 2008, 84,270 people with HIV received care and support

with direct USG support (17% coverage).

Access to ART is improving, with continuing progress in scaling up services. With USG support, the National HIV/AIDS Care and

Treatment Program (PNPEC) expects to meet the PEPFAR and national five-year target of 77,000 people on ART by September

2009. As of September 2008, 40,329 people were receiving ART at 160 sites with direct USG support, and the Global Fund (GF)

was supporting 9,906 and UNICEF 323 ART patients. With client accrual of more than 1,600 per month, the USG team expects to

be treating 60,000 patients (92% adults) by September 2009.

PEPFAR-supported care and treatment services are provided by EGPAF, ACONDA, and ICAP Columbia University, with a new

partner planned for FY09. With collaboration from the PNPEC, the USG has adopted a regional approach to improve program

monitoring and service quality: Services in Ministry of Health (MOH) facilities in the mideastern part of the country are assigned to

EGPAF, those in the far west to ACONDA, and those in between to ICAP. Abidjan and surrounding areas are supported by both

EGPAF and ACONDA. Facilities in the lower-prevalence and conflict-affected North and West receive support through the GF,

although implementation of services has been weak.

FY07-08 Response

Adult Care and Support

The national palliative-care policy (finalized in FY06 with USG support) defines minimum standards of care for clinic, community,

and home settings, and an implementation plan outlines training and supervision approaches. These guidelines incorporate

guidance on cotrimoxazole prophylaxis (recommended for all HIV-infected persons with CD4 counts <350), but systematic

provision has not been achieved. Most programs also support treatment for OIs, malaria, and STIs; basic pain management;

screening for TB; and psychosocial support. Some programs are working to incorporate provision of insecticide-treated nets

(ITNs), nutritional assessment and supplementation, HIV testing for family members, and interventions to improve hygiene and

water safety.

In FY07-FY08, PEPFAR continued to support the PNPEC in developing a comprehensive care and support program and

integrating it within the continuum of care as defined by national standards. Guidelines for community-based care and support,

policy documents on nutrition for PLWHA, and guidelines on the use of opioids were developed, followed by training of providers.

The PNPEC has validated a policy defining the scope of work, recruitment process, and salary scale of lay counselors to be hired

in support of prevention, care, and treatment services at health care centers and in the community. Despite important

accomplishments, the number of adults receiving quality care is a small proportion of those in need, and linkages between facility-

and community-based programs are poorly defined in some regions. There is a need to improve linkages to other programs (e.g.

TB centers, ART sites, PMTCT clinics, and CT) and to expand integration of preventive services into care programs.

Adult Treatment

As of June 2008, the PNPEC listed 177 accredited ART sites, of which 143 were receiving direct PEPFAR support. (By

September, PEPFAR partners were supporting 160 sites.) The functionality of GF sites has been incomplete due to lack of

biological monitoring and ongoing support, resulting in an increased patient load at PEPFAR-supported sites in some regions.

The basic HIV clinical treatment package provided by USG partners includes ART, cotrimoxazole prophylaxis, biological

monitoring, and limited OI prevention and care, with links to community-based care and support. Improved data management and

use include longitudinal follow-up and ARV-resistance evaluations. The PNPEC has revised national guidelines on ART and basic

laboratory monitoring tests for ART patients, including a shift from a D4T-containing regimen to an AZT-containing regimen as the

first line for all patients infected with HIV-1. A first-line regimen containing a protease inhibitor (lopinavir) continues to be

recommended for HIV-2 and HIV-1/2 (dual) infections. In August 2008, the MOH discontinued its ARV cost-recovery system,

offering ART free of charge for all adult patients. This act of political will is likely to increase the number of patients receiving ART.

The USG is providing continued technical and financial assistance to train trainers in service delivery, to support TOT for ARV

providers, and to develop treatment performance standards. PEPFAR partners are continuing to promote better support and

referral systems, better interpersonal communication for more effective care and treatment, and mass-media campaigns to

promote CT, raise awareness of available HIV/AIDS services, and reduce stigma and discrimination.

A number of implementing FBO/NGO/CBOs are being funded through a performance-based competitive sub-granting process in

an effort to address barriers such as lack of motivation of personnel and human-resource deficits, especially in the North. The

USG supports the implementation of a network model with linked services at the regional and district levels. District pilot models

are used to develop and evaluate a comprehensive approach featuring a continuum of care with community mobilization and

follow-up. In FY08, implementing partner activities are promoting referrals to clinical care for PLWHA at the district level.

Priorities for FY09

Care and treatment strategies in FY09 will focus on evidence-based, lifesaving interventions; training and supervision for care

providers; and strengthening of support and links through trained, full-time counselors at all sites. Key goals in FY09 include:

1. Increased geographic and population coverage. Based on the new regional approach, USG implementing partners will continue

rapid expansion of services with a goal, by September 2009, of supporting (i) 174,800 non-ART-eligible adult patients at 490 care

and support sites (excluding TB); (ii) 55,200 adult patients on ART at 255 sites, including sites in all 19 regions of the country

down to the district general hospital level and in some cases to the community health center level.

2. Systematic provision of cotrimoxazole as the most important evidence-based means of decreasing morbidity and mortality,

delaying disease progression, and improving quality of life. The current policy for CTX prophylaxis is to provide CTX to adult

patients with CD4<350. USG will continue to work with PNPEC to change the policy in order to provide CTX prophylaxis to all

adult HIV-positive patients regardless of CD4 count. ITNs will be provided through care and support programs in regions not

covered by the Global Fund Malaria Project, prioritizing high-risk groups (pregnant women). Clean-water kits (container and

chemical) will be provided to patients in regions with low water quality.

3. Improved linkages between facility- and community-based services and between care, and treatment, and other services will

ensure that more patients benefit from a continuum of quality HIV/AIDS services. All PEPFAR-supported ART, PMTCT, and

HIV/TB service providers will be funded to engage counselors at all sites who will provide a comprehensive package of HIV

prevention interventions for all clients and effective support, follow-up (including provision of medications where feasible), and

referrals to community-based care and support services for HIV-positive clients. All PEPFAR partners providing community- and

home-based care and support will be funded to cross-train their community counselors to provide OVC services. For maximum

effectiveness, partners will be encouraged to engage PLWHA in these positions.

4. Improved reach and quality of care and treatment services. In FY09, PEPFAR-supported programs will reach about 174,800

adult patients with care and support. Quality improvements will include efforts to strengthen training and supervision for facility-

and community-based care providers; to promote systematic screening for TB; to improve nutritional assessment and support; to

reduce loss-to-follow-up before initiation of ART; to diagnose and treat OIs, piloting cervical cancer screening among sex workers

and other high-risk populations; and to pursue opportunities for wraparound services with other donors/partners, such as provision

of heavily subsidized ITNs through the Global Fund, clean-water commodities through the private sector, and nutritional support in

partnership with the World Food Program.

5. Ensure that supportive policies and practices for HIV-related care and treatment are in place. Several partners will continue to

work with the PNPEC and stakeholders to implement supportive policies related to opioid availability; to implement the new

national HIV rapid-testing algorithm using finger prick, and a redefinition of the role of non-medical health professionals and lay

persons in performing HIV tests and prescribing or supporting certain medications. The issue of caregiver burnout will be

addressed in topical meetings and through technical assistance to partners.

6. Improved ART performance with reduced losses among adult patients. USG partners will focus on providing high-quality care to

ART patients with greater access to services, uninterrupted availability of commodities, and systematic accreditation and site

openings. A key objective will be to improve coordination, planning, supervision, and training at site and district levels. Links to

community- and home-based care will be strengthened, along with expansion of routine, provider-initiated CT in health facilities,

and outreach to families. Efforts to improve ART adherence will focus on counseling - both facility- and community-based - that

also addresses issues of stigma. To ensure quality, PEPFAR partners will assist in the development and implementation of

performance standards for all clinic-based services. National care and treatment guidelines will be updated, and clinicians will

receive refresher training via regular supervision and continuing medical education. Training, supportive supervision, career

progression, and expanded peer and community services will be used to address human-capacity barriers and improve the quality

of care. Basic Program Evaluation (BPE) and Public Health Evaluation (PHE) will be conducted to assess the quality of the ART

program and the efficacy of evidence-based interventions to reduce early mortally of adult patients on ART.

7. Gender sensitivity as a component of quality care and treatment. The feminization of the generalized epidemic requires greater

gender awareness in all aspects of care and treatment, including disclosure of HIV status, since a disproportionate number of HIV

-infected women are in sero-discordant relationships. Strategies will include positive-prevention interventions, especially for

discordant couples; promotion of partner and family HIV testing; and stigma-reduction campaigns with an expanded role for peer

support and peer advocacy.

8. Ensuring availability of drugs and commodities. Most HIV-related drugs and consumables will be centrally procured through

SCMS, which will also continue providing technical and management support to the Public Health Pharmacy (PSP) to ensure

uninterrupted supplies of needed commodities.

Pending OGAC approval, PEPFAR CI will strengthen its evidence base in care and treatment through three public health

evaluations (PHEs) assessing 1) the effectiveness of EGPAF's care and treatment program, 2) interventions to reduce early

mortality among patients initiating ART (an inter-country PHE), and 3) care and treatment of patients with HIV-2 infection. The last

will serve to create a research platform for further studies, and its findings will have regional implications and provide data for

WHO guidelines on HIV-2 infection.

PEPFAR care and treatment partners will link with partners supporting community services (ANADER, ANS-CI, and RIP+). Care

International will continue to support local organizations providing care in the North and West, and PSI will continue a program

focused on care for the uniformed services. The Ministry of Education will continue a program focusing on teachers, and FHI will

continue programs targeting sex workers. The African Palliative Care Association will twin with Hope Worldwide CI to support

continued advocacy for a pain management/opioid policy and implementation of palliative care standards. FANTA will continue to

assist the PNPEC and the National Nutrition Program (PNN) to strengthen nutrition policy and support.

Cote d'Ivoire's Round 8 application was not successful. After the Round 2 HIV project ends in March 2009, it is expected that the

GF will continue to provide ARVs and lab commodities to support its current patients. The USG team is represented on the CCM

and in regular consultation with the GF principal recipient, and is prepared to help address potential programmatic implications of

a GF service-delivery gap as well as to join MSH in providing technical assistance for an expected GF Round 9 application.

When possible, the USG provides complementary programming with other donors and partners, such as the Global Fund for ARV

procurement and the WFP for food aid. The USG promotes sustainability by transferring technical, financial, programmatic, and

M&E skills from international organizations to local CBOs, NGOs, FBOs, and ministries while building their capacity for program

management and accountability.

Table 3.3.08: