With USG support, the Ivoirian rural-development agency ANADER works to increase access to HIV/AIDS prevention, treatment, care, and support in rural areas by providing evidence-based prevention, care, and referral services. Working through community social action groups and community counselors in villages, the project aims to: 1. Promote healthy behavior change to reduce HIV transmission; 2. Reduce HIV vulnerability among women and girls; 3. Build local uptake of PMTCT services; 4. Provide close-proximity HIV testing and counseling in high-prevalence areas; 5. Improve community care and support for people living with HIV and OVC; 7. Foster local ownership of HIV/AIDS activities by communities and local authorities. Cost efficiency is pursued by targeting densely populated rural sites to maximize peer educator and community counselor (CC) use, prioritizing local procurement, and conducting training and on-site in ANADER centers and religious facilities using ANADER staff. High-performing agents and CCs will be trained to be supervisors to reduce monitoring and supervision costs. Capacity building in M&E will produce more qualified staff for activity monitoring, accurate data gathering and verification, and field level evaluation of interventions.

Vehicles: Through COP11: 0. The program is running on two used ANADER-owned vehicles. New requests in COP12: 4 ($160,000) for nationwide supervision activities. Total planned vehicles for life of mechanism: 5.

ANADER 2012-13 adult care and support activities will consist of capacity development for community counselors (CC), ANADER rural development agents, and people living with HIV/AIDS (PLWHA) and their families in palliative care and psychosocial and nutritional support. Prevention with Positive (PwP) activities will focus on training of field actors and PLWHA support group leaders. Sensitization of PLWHA will focus on medical check-ups, ART adherence, systematic and appropriate use of condoms, and creating support groups. With the contribution of Heartland Alliance, commercial sex workers who have been identified and tested positive will be supported and monitored by CC, and will be provided with condoms and lubricant. They will also receive education against drug and alcohol abuse. PLWHA will be educated on identifying signs of sexually transmitted infections (STI) and on hygiene such as washing hands.

These activities will be extended to 32 new village sites. The target population is people living with HIV/AIDS, especially discordant couples.

PLWHA are identified through the projects mobile HIV testing, home-based testing, or testing at rural health centers, and offered support after they confide in CC.

Community social action groups (ECAS) created with the projects help, in charge of implementing HIV/AIDS and other activities in the village, will help foster good working rapport between health workers and CC). Wherever possible, CC from ECAS will assist in group testing and counseling at health centers. This shared responsibility will build CC recognition in the clinical and community settings and facilitate greater ease of follow-up through home visits of consenting, newly identified PLWHA. Where barriers arise that limit CC from providing supportive services at the health center (e.g. space, time, client loads, distance), health workers will refer PLWHA to the CC covering the specific area. With the use of the OVC pre-identification slips designed by ANADER and mobile and home bases testing approaches, PLWHA will continue to be identified for care and support services. Regular home visits to PLWHA by CC will help keep them in the system of care and support. During these home visits, CC will ascertain whether the clients referred to care and treatment services have had their medical checkups.

To improve quality of services, emphasis will be put on enhancing community involvement in HIV/AIDS interventions. A focus on addressing stigma and discrimination will help attract family members in care and support activities that might otherwise have been missed. Through support groups, PLWHA IGA will be financed and awareness on healthy positive living increased.

ECAS composed of community members will lead HIV/AIDS activities. Appropriate needs assessment tools and documentation of effective local solutions will be developed. PLWHA peer support group members will be trained to join/assist CC to provide appropriate support to their peers. Food security threats will be taken into account by giving nutritional counseling, providing therapeutic food to PLWHA with the assistance of the World Food Program, and through IGA for those especially vulnerable.

Hygiene kits (clean-water systems, male condoms, and lubricants) are provided to PLWHA, and condoms and lubricants are made available at community outlets in areas identified as hot spots.

By September 2013, the project will provide care and support for 11,124 children and their families. Community counselors (CC) will identify OVC while providing initial support to people living with HIV/AIDS, and based on childrens assessed needs will provide psychological and spiritual support, support for education and trade learning, access to health care, legal support, shelter, and economic strengthening.

Strategically, 378 individuals will be trained in OVC care and support, including quality improvement standards for OVC service delivery, age-appropriate counseling, and food and nutritional support. In each village site of the project, 3 CC and 1 rural development agent will receive training. At each new ANADER district head office of the project, 2 agents will receive similar capacity building.

Psychosocial support: Support groups of OVC will be created on village sites to help address mental and social needs and help children better integrate into their family or community without stigmatization and discrimination. Reporting will continue to focus on the number of OVC who actually participate in these activities.

Schooling and trade/vocational learning: 2,500 OVC will be targeted for enrollment in retention activities. Their parents or guardians are sensitized on the benefits of learning and safety/protection issues. Where there is a dire need, the program will work through local structures to assist with school fees, kits, basic food, and shelter. . Selected OVC beyond school age will be enrolled in vocational training in a workshop or training center.

Supporting health care: HIV-positive OVC are followed up by CC. Home visits are done to persuade parents/guardians to support the child in ART adherence and respect appointments for medical check-ups. When it is noticed that an appointment is missed, a CC will contact the ANADER local district to assess the situation or assist with transportation. In cases of extreme poverty or clinical need, some hospital fees will be paid or drugs for opportunistic diseases will be provided.

Legal support: Child rights will be promoted through sensitization (including local radio programs) and support of OVC families to:

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Register the baby before the age of 3 months

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Obtain birth certificates for older OVC

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Fight against physical ill-treatment and child labor;

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Encourage school enrollment, especially for girls

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Increase knowledge and prevent other harmful practices such as female genital mutilation

Household strengthening: To address the large number of OVC attending school without food or money to buy lunch, support will be given to an agricultural association in the village to produce food material and supply school canteens. OVC guardians will also receive financial assistance for income generating activities to enable them to support the children in their care. With the use of the Child Status Index, the effects of direct services to OVC will be evaluated after six months of support.

By September \2013, ANADERs HIV/AIDS rural program will have reached 11 regions and 26 departments where the HIV prevalence rate ranges between 3.2% and 6.1%. Activities will be implemented in 220 village sites.

AB field interventions will rely primarily on peer education using an accredited curriculum and outreach activities appropriate for the various target groups. 15- to 24-year-old male and female youth will be selected in the community, then trained in behavior change communication (BCC), HIV/AIDS/STI, and risk reduction (e.g. related to intergenerational and multiple partnerships). They will sensitize their peers during an average of four to six sessions gathering 15-25 participants. Training will be followed by coaching and supportive supervision by ANADER agents previously trained on the topics. Assessments of knowledge and attitudes will be conducted before and after sessions.

Older women are involved in the program as beneficiaries as well as actors. Womens association leaders will be educated on gender-based violence (GBV) prevention and response; faithfulness; rights of women, children, and the elderly; and social protection issues for HIV-affected households/communities. They will facilitate on-site awareness sessions within their associations.

In support groups, persons living with HIV/AIDS (PLWHA) will be coached to lead sessions with their peers. Topics will range from prevention with positives, specifically behaviors/practices to prevent new infections or reinfection and approaches that increase well-being in families of PLWHAs (e.g. related to GBV and other priority issues identified).

Couples identified with support from village and religious authorities will be designated as champion couples and will be educated/trained on mutual faithfulness, risks from multiple sexual partnership, and STIs. Champion couples will sensitize other couples in the community. Messages on being faithful, multiple sexual partnership, and STI will be broadcast on national radio and discussed through listening groups formed at each site to stimulate further understanding of information and tools discussed on the air. . These activities will be conducted with technical support from JHU/CCP.

Target audiences include:

- youth 15-17 years old who have never engaged in sex;

- sexually active youth 15-25 years old;

- girls and women 15-34 years old potentially exposed to sexual abuse and violence;

- couples;

- members of farmers field schools and associations

Among target groups, highly vulnerable individuals who do not know their HIV status will be encouraged to seek HIV testing and counseling services. During awareness sessions facilitated by women leaders, discussion topics will include condom negotiation, GBV, and risks associated with multiple sexual partnerships. Sensitization for couples testing and status disclosure will be prioritized.

Young peer educators, womens association leaders, support group leaders, champion couples, and ANADER agents will be trained or educated on their specific topics of intervention, then be coached on basic counseling to help themselves and community members adopt healthy behaviors and seek HIV or other health services.

Two approaches will be used to reach the target populations, mobile testing and counseling (TC) and home-based testing (HBT),and will be promoted through leaflets, posters, and local radio. JHU/CCP will provide technical assistance. Peer educators, leaders of women's associations, and trained champion couples will promote TC during sensitization sessions.

Both HBT and mobile TC will be conducted by community counselors (CC). Testing will be supervised by health district staff. Emphasis will be put on sensitization of households of people living with HIV/AIDS (PLWHA) who are being supported by CC. Testing will be proposed to the entire household. Community social action groups (ECAS) created with the projects help will be in charge of implementing activities against HIV/AIDS in the village, with the support of CC, peer educators, leaders of womens organizations leaders, religious leaders, etc.

Mobile TC: The aim is to reach vulnerable populations in zones of high HIV prevalence (up to 33%, according to a 2009 study). These targeted populations will be linked to the program by ECAS members, who are familiar with village hot spots of economic and social transaction and high-risk behavior. The ANADER mobile TC program targets agricultural industries, hydro electric plants, fish monger areas, and mining zones.

HBT: This approach in a community setting will target pregnant women, their spouses, highly vulnerable populations, and family members of PLWHA. Couples TC will be emphasized to help facilitate the sharing of test results bypartners.

Training of CC and ANADER rural development agents will be organized with the National HIV/AIDS Care and Treatment Program (PNPEC) and will use the national trainer pool. PNPEC will accompany supervision missions.

For the two approaches, testing will be conducted using the third national algorithm (Determine and StatPak). HIV-positive clients will be referred to the nearest rural health center and, as appropriate, to the nearest HIV care and treatment services. CC will ensure that PLWHA are linked to community-based care and support services (including OVC services) through home visits and follow-up tracking.

ANADER will provide financial support to health districts for management of biomedical wastes from both TC approaches. . Biodegradable organic wastes will be destroyed in secure places at nearby health centers. Other types of wastes will be transferred to containers and disposed of safely by the health district.

TC activities be conducted in close collaboration with health districts. Quality control will be ensured by the districts quality assurance staff during HBT. Lab technicians and nurses will participate in and supervise mobile TC.

ANADER will also participate in National HIV Testing Day.

By the end of 2012-2013 budget period, ANADERs HIV/AIDS rural program will have reached 11 administrative regions and 26 departments where HIV prevalence rate ranges between 3.2 and 6.1%. Activities will be implemented in 220 village sites.

Target population will originate from villages and consist of:

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Professional sex workers around agricultural plants;

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Men and women over 25 years of age, in associations and/or in farmer field schools;

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Sexually active young people ages 15-25 years;

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Couples where at least one partner is between 25 and 49 years old;

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People living with HIV/AIDS;

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Seasonal agricultural workers.

Leaders among professional sex workers, PLWHA support groups, champion couples, farmer school members, community counselors, and ANADER workers will receive training on correct use and systematic use of condom.

All target populations will be sensitized on correct and systematic use of condoms. They will be provided clear knowledge on signs and symptoms of common STIs in order to seek early care and treatment in the closest health facilities. Moreover, they will be sensitized on PMTCT, testing and counseling, and other injury prevention issues such as precautions in the use of sharp objects / tools and protection with gloves. Sensitization will also be conducted on HIV infection risks associated with alcohol and drug abuse. Individuals who do not know their HIV status will be oriented toward HIV testing and counseling facilities.

At each intervention site, accessible and clearly identified condom sale outlets will be created mentioning opening hours. Care will be taken to store and monitor condom packs in appropriate storage conditions (heat, humidity, etc.) to maximize good product quality and renew stocks periodically. Program coordination will link up AIMAS (Agence Ivoirienne de Marketing Social) and condom outlet managers, which will help create opportunities for sustainability through local distribution channels.

PMTCT promotion activities will be implemented in 75 village sites in 26 departments (14 new) and 11 regions. ANADER will support health care workers to promote PMTCT services in the community and encourage mothers who have received PMTCT services to test their babies for HIV.

Based on a community/health facility referral model tested in 2012, ANADER will partner with PEPFAR partners implementing PMTCT interventions in village health centers. Community counselors (CC) will sensitize women of childbearing age through informational home visits and facilitated sessions with womens associations and support group meetings to avoid HIV infection, prevent unwanted pregnancies, increase attendance at antenatal consultations and observe appointments and treatment regimens. They will direct pregnant women toward health centers for ANC and HIV testing and follow up with HIV-positive clients enrolled for PMTCT. Emphasis will also be put on spouse sensitization to raise greater awareness of PMTCT and encourage more partners to accompany their wives to the first ANC. HIV-positive mothers follow-up will continue through breast feeding and nutritional counseling until the child is tested for HIV. Traditional midwives will be trained on a community PMTCT module designed to help them motivate pregnant clients to do regular ANCs and refer them to certified midwives for care.

The partnerships with facility-based partners wil emphasize linkages between health care facility and community service. Thus, community follow-up will be made easier when professional midwives inform village CC of notices sent to pregnant womens husbands/companions. Consultation fees will be waived for couples attending their first ANC together. In addition, health center midwives will regularly provide CC with updated information on clients lost to follow-up to allow for these women to be identified and brought back to the health facility. After delivery, HIV-positive mothers who have honored all four ANC appointments and carried out PMTCT enrollment correctly will be given a hygiene kit comprising bleach, detergent, and soap.

CC, womens association leaders, traditional midwives, and ANADER agents will be trained in a community PMTCT module with onsite coaching to support the delivery of high quality services.

A documentation review will assess initial status of rural and urban health centers (e.g. PMTCT uptake, lost to follow-up rate, etc.). Reporting on PMTCT activities will occur on a monthly basis by CC. These reports will be checked for accuracy by the village site rural agent, then submitted to the ANADER district office for compilation, analysis, and transfer to PEPFAR-ANADER Program coordination. All implementers (professional and traditional midwives, CC, association leaders) will participate in periodic exchange meetings to foster synergy across interventions, routine activity appraisal, and timely response to difficulties. Quarterly supervision will be conducted by ANADER technicians and regional officers.