Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has received USG funds to assist the

Ministry of Health (MOH) in supporting and expanding quality HIV/AIDS prevention, care, and treatment

programs while building on and complementing other programs supported by PEPFAR, the Global Fund,

UNICEF, and others. EGPAF works to implement a family-centered approach in delivering HIV services.

By the end of Project HEART PY5, EGPAF will support 100 ART sites and will have more than 35,000

persons on ART. EGPAF will continue modest expansion in FY09 to an additional 15 sites and initiate

14,400 new persons on ART.

Through the district approach, ART services will be extended to rural areas in 14 targeted districts. In each

district, EGPAF will work with the district team to establish a network of facilities that will link one well

established ART site in an urban or peri-urban area with two or more rural ART sites. The urban sites will

then supervise and monitor the rural sites.

In FY08 EGPAF supported performance-based financing in 20 private and faith-based facilities.

CHU/Treichville will be the first public sector facility to implement performance based financing (direct

funding is possible due to CHU/Treichville's legal status). In FY09 EGPAF will add ten additional private

performance based sites in Abidjan. The expanded PBF approach should contribute to both the number of

patients enrolled in treatment and retained in treatment at these sites.

EGPAF will continue to expand public-private partnerships building on the successful experience with

SOGB to enable Ivoirian businesses to offer ART to employees. EGPAF would like to use the PBF

approach in the private, for-profit sector as this represents a major proportion of health services in urban

areas. However, EGPAF will need to advocate and work closely with the MOH and other relevant

departments as well as the PEPFAR team in-country to make this happen.

EGPAF intends to increase full laboratory support for patients receiving ART as well as patients in Pre-ART.

To attain these goals, with close collaboration with SCMS and with technical assistance of CDC lab branch,

new districts hospitals will be provisioned with equipment for measuring CD4 count, hematology,

biochemistry. Bases on SOPs validated in PY5, EGPAF will provide technical assistance to existing labs as

well as new labs to be established in FY09.

Focus in FY09 will be on the implementation of a comprehensive package of services to improve the overall

quality of services provided at all EGPAF-supported sites and address critical issues including attrition rates

within the program. Addressing these issues is part of a broader quality improvement program undertaken

in PY5 with the support of a subcontractor, John Snow International.

EGPAF will continue efforts to address QA/QI issues: districts QI teams will be developed and will lead in

improving quality of care in the districts under the supervision of EGPAF and Senior Health Management

Teams. Health facilities that perform well will be rewarded at the end of the PY with medical equipment and

infrastructure renovations. With PY6 funds, EGPAF will be working with many local CBOs to improve

services uptake. These CBOs will work closely with medical teams to address issues related to reinforcing a

family centered approach, adherence to treatment, and minimizing loss to follow up,.

Special emphasis will be put on activities in the underserved North of the country. In order to improve the

coverage of activities in this area EGPAF will continue building on close collaboration with Health Alliance

International and Unicef.

In both performance-based and cost-reimbursable formats, direct support to sites is provided in accordance

with national standards in terms of commodities, equipment, trained staff, laboratory services, and M&E.

Implementation is coordinated with PNPEC and may be direct (public sites) or through implementing sub-

partners. EGPAF seeks to ensure continuum-of-care services and service promotion at the community and

home levels (through partnerships with the network of PLWHA organizations, Alliance CI, CARE

International, ANADER, and other partners).

EGPAF works with SCMS and the Public Health Pharmacy (PSP) to support quantification and provide ARV

drugs and commodities at supported sites. Laboratory services are coordinated with the Ministry of Health,

APHL, CDC/Projet RETRO-CI, and the national network of laboratories.

FY09 funds will permit EGPAF to provide ongoing support to the planned 100 sites and 35,000 patients

expected to be on active ART by March 2009 as well as to provide services to 15 additional sites, for a total

of 36,700 people on active ART by September 2009.

While activities described above will provide the framework for care and treatment, several new initiatives

will be promoted to further strengthen the program. These include:

• Collaborate with local organizations to intensify HIV services promotion in the community and to

strengthen the capacities of community-based organizations;

• Further refine the performance-based contracting model and shift some partners currently supported

through cost-reimbursable grants to PBC;

• Expand the EGPAF quality assurance system to all supported sites;

• In collaboration with local NGOs and CBOs directly supported by EGPAF, EGPAF will work more closely

with social workers and community counselors (including PLWHA) to improve adherence to treatment,

reduce loss to follow-up, and provide psychosocial support, OVC care, and prevention for positives

interventions.

In a further attempt to institutionalize and make sustainable the activities supported by EGPAF with

PEPFAR funding, EGPAF's recent partnerships with and support of the National Medical and Social Worker

training institutions will be expanded to increase the human resources available to Côte d'Ivoire to fight the

HIV epidemic, prevent new infections, and treat people already infected with the virus.

Activity Narrative: In addition to the technical assistance received from CDC/Retro-CI for quality assurance for HIV testing,

EGPAF will seek technical assistance locally to address urgent issues related to QA for biochemistry and

hematology exams, including development of standard operating procedures and good clinical laboratory

practices.

EGPAF also plans to conduct an evaluation of strategies for retaining HIV-positive patients in care and

delaying progression to ART eligibility.

At all its PMTCT and ART sites, EGPAF will provide - through direct hire or, more commonly, by contracting

with individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for persons living with HIV/AIDS and their

children.

EGPAF will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

HIV-negative clients at PMTCT, CT, and TB sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT, ART, TB, and CT sites:

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a counselor for

individual counseling that will include HIV prevention interventions and referral to community-based OVC

and palliative care services to address family and individual care needs now and in the future. Targeted HIV

prevention counseling will focus on risk reduction through abstinence, fidelity, correct and consistent

condom use, disclosure, testing of partners and children, and STI prevention and care. Where possible,

family-planning counseling and services will be provided to patients and their partners through wraparound

programming by other non- PEPFAR funded partners, and condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. In these individual sessions,

the counselor will seek to obtain contact information (e.g. address, telephone number) for the client and

briefly assess the client's needs and resources. The counselor will provide the client with a brochure or

other illustrated materials showing what the palliative care and OVC care services might include, such as

clean water and bed nets for palliative care and educational, medical, nutritional, legal, and psychosocial

support for OVC. The counselor will then ask the client whether she or he would like to provide the names

of people in the household who might need referral to such services.

With assistance from the National OVC Care Program (PNOEV) and the PEPFAR in-country team, EGPAF

will ensure that community-based services capable of meeting these needs are identified, and EGPAF will

be responsible for monitoring and reporting on referrals according to a nationally standardized referral

system.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services for persons living with HIV. The program's effort will

reflect the funding and proportions noted here.

Sustainability

In FY08 EGPAF demonstrated that improved capacity, coordination, and engagement of the district health

team through a district approach enabled rapid scale-up of services in Abengourou and Agnibilekro districts.

Though a funding mechanism by which funds can be appropriated directly to a health district has not been

established, EGPAF plans to expand the district approach in FY09 to 14 districts. EGPAF will provide: 1)

basic infrastructure support such as conference space for district meetings and trainings, basic equipment

and minor renovations to offices, pharmacies, laboratories and health facilities; 2) training of trainers for

regional and/or district teams to conduct refresher trainings in districts; 3) laboratory equipment and

facilitation of a lab network and logistic arrangements for the transport of samples to referral labs when not

on site; 4) consumables and lab reagents; 5) transportation in the form of vehicle(s) for high performing

districts; 6) supervision and coaching of health care workers; 7) reinforced management capacity through

action plan and budget development as well as national and international courses. Over time, once the

district team takes the lead in planning and implementing activities, EGPAF's role will be reduced to

technical assistance.

In-service training of health care workers is a continuous process due to transfer and attrition. Off-site

training is expensive and contributes to human resource shortages. The next generation of health care

workers must be trained pre-service. Currently practical clinical training occurs at urban tertiary care centers

not representative of the majority of public sector settings in which providers in Cote d'Ivoire will work. In

FY08 EGPAF initiated a program with two national training schools to provide practical pre-service training

for medical and social work students in HIV, malaria and TB. Nineteen medical and 50 social work students

were given theoretical training and completed a six month internship at an EGPAF-supported site. In FY09,

EGPAF will expand both of these programs to include 50 additional medical and 100 social work students.

Based on the success of the program, in FY09 EGPAF will sign agreements with the pharmacy training

program for placements for 25 students in drug supply chain management and the nurse midwife training

Activity Narrative: program for placements of 25 midwives in PMTCT programs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15109

Continued Associated Activity Information

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

System ID System ID

15109 5495.08 HHS/Centers for Elizabeth Glaser 7044 4937.08 EGPAF Track 1 $6,422,257

Disease Control & Pediatric AIDS ARV (Level

Prevention Foundation funds)

9721 5495.07 HHS/Centers for Elizabeth Glaser 4937 4937.07 EGPAF Track 1 $6,722,257

Disease Control & Pediatric AIDS ARV (Level

Prevention Foundation funds)

5495 5495.06 HHS/Centers for Elizabeth Glaser 3711 3711.06 EGPAF Track 1 $3,205,429

Disease Control & Pediatric AIDS (level funds)

Prevention Foundation

Emphasis Areas

Construction/Renovation

Health-related Wraparound Programs

* TB

Military Populations

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $500,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09: