The general objective of the Aconda program for PEPFAR II is to consolidate the accomplishments of our HIV care program in order to ensure the sustainability of HIV care activities in the health system.The implementation will be based on two strategies which are firstly, the district approach with its institutional and operational components and secondly, the regional approach.The district management team (ECD) will be involved in the coordination of activities, ARV and other strategic consumables supply. The ECD capacities will be strengthened and they will be provided with equipment and technical support. Focal persons will be identified within the ECD according to the themes to monitor specific activities and supervise health workers. The regions are the administrative authority for the district. Our strategy will be to reinforce health regions in order to help them maintain the link with the entire district.The Aconda program will contribute to improve datas circuit respecting the national three ones principles, to strengthen capacity building of health workers particularly for CSE in Monitoring and Evaluation, data validation, analysis, quality control and the use of strategic information. We will also improve the use of national standards at different levels of health pyramid.Through COP11, funds were needed for 13 vehicles. We have a new request for 2 vehicles and 20 motorbikes in COP12. The total planned vehicles for life of mechanism are 15. Request justification concerns 1 vehicle ($35,433) will be used for coaching 138 supported health facilities in 9 regions and 1 vehicle ($15,748) for use in Abidjan for routine project activities. The 20 motorbikes ($49,214) will be used in districts to collect data, transport blood samples and follow up HIV activities.

Care and support services for adult patients will be set up at each site using a comprehensive care approach and continuum of care. Technical assistance, equipment, other information resources will be given to the 138 functioning sites and the 9 sites that have to be renovated. People that test HIV positive will be informed of the circuit inside the health center and the link between the health facility and the community. Adolescents, adults men and women, pregnant women represent the target cell for this programmatic area. The promotion of care service offered in health center and out by mobile teams in community will be known by beneficiaries through sharing leaflets and other communication channels. Component of care and support basic package will be cotrimoxazole, pastilles for water purification, insect treated nets, (supported by SCSMS) in addition to hygiene, psychological consultation and therapeutic or supplementary food for malnourished patients which will be in collaboration with PNN. Screening for tuberculosis among PLWHA will be done with the existing support of PNLT and the data collection will be reinforced in HIV facilities. The same day blood sample is taken if the site has a laboratory delivering a full lab service or with an appointment when full lab tests are not available on site. A second visit will be planned according to the management period given before receiving results. The MD initiates ART services according to national guidelines, gives information on drugs, counseling on adherence and the patient goes to the pharmacy to collect ART drugs. The patient is also seen by nurse or trained CC for adherence evaluation who with patients consent, will obtain his/her geographical address and propose to accompany him/her home. Patients on ART services are seen every 3 months by the MD. Patients not yet eligible for ART services will be seen every 6 months for clinical support. Based on assessment findings of the initial pilot project, PwP activities will be consolidated at the 52 existing sites and an expansion program will integrated into activities in all other sites with the main focus made on the Mother and child health services, family planning services and ART services. Focus groups will be organized such as with PwP associations that may help patients remaining in care reduce lost to follow-up, improve quality of life of PLWHA, and learn how to live positively. PLWHA group members can also be trained as peer educators and more engaged in the HIV/AIDS response. A specific emphasis will be put on HIV discordant couples. Distribution of basic tools such as PwP reference card, picture box, posters, leaflets, condoms and artificial penis for demonstration will be continued. Focal points will be identified at the district level among trained care actors providing them with materials and technical assistance to manage and to support the PWP implementation sites according to national guidelines. The health staff will be trained in STI syndromic care and benefit from STI care kits and consultation with PSP that will be offered to diagnosed patient visiting the health center every 3 months. With JHPIEGO, Aconda supports 3 health facilities where cervical cancer screening is proposed and organized. Aconda will promote cervical cancer screening in all sanitary district supported throughout care provider sensitization to reach all PLWHA.

In tuberculosis centers after systematic counseling, information on services is given following HIV testing. TB patients will be proposed and tested with the finger prick method. That method will be set up called CAT/CDT. TB patients that test HIV positive will receive care according to the TB/HIV national algorithm. At service outlets offering CAT/CDT, Aconda in collaboration with PNLT will identify, rehabilitate and equip those centers to manage TB infection control. Aconda will systematically provide coughing and spitting TB patients with protection masks.

In HIV care center, the medical doctor or nurse trained in TB/HIV co-infection Care and Treatment will carry out the systematic screening of patients tested HIV-positive based on the tuberculosis symptoms form established by PNLT and PNPEC. This strategy will be implemented in PMTCT services and in HIV pediatric care. In the case of TB diagnosis or treatment, PLWHA will receive TB services on site (HIV site offering TB drugs) or in a CAT/CDT accompanied by a CC with a reference and counter reference form. Aconda will provide currently PNLTs TB screening form in all supported health facilities and will ensure accurate patient records. The health service providers of TB and HIV will be trained in directly observed treatment short course (DOTS), PICT with Finger Prick, filling out referral and counter referral forms. On the TB and HIV sites, all those who use the services of these sites will be sensitized in the waiting rooms by the CC. All tuberculosis patients will undergo HIV testing and will receive biological and therapeutic care and treatment in the CAT/CDT. Referral and counter referral activities of patients having recovered from tuberculosis will be carried out through CC towards HIV Care and Treatment centers. The improvement of reference and counter reference in TB centers and in HIV/AIDS care centers will be the major objective of Aconda during COP12. Aconda will work closely with CAT/CDT data manager in order to get effective data. In TB/HIV care service outlets, Aconda will establish a link between the HIV/AIDS identification number and the TB identification number which will be notified on the TB chart only in the patients records. TB-MR survey and supervisory visits covering the geographical areas CAT Abobo, Daloa, Gagnoa, and Odiénné will be organized in close collaboration with PNLT and PNPEC. Training supervision workshops will be organized for healthcare providers by district care focal point with Aconda collaboration on all service outlets. Quality improvement team will be set up on the services outlets. They will be monitored by URC and defined their own quality objective according to URC quality process.

The Ivoirian NGO ACONDA works to build Ministry of Health and AIDS (MSLS) capacity to expand access to quality comprehensive HIV/AIDS prevention, care, and treatment while contributing to sustainable service delivery and attainment of national strategic plan targets in nine regions of southern, western, and northwestern Côte dIvoire.

Care and support services will be provided for infants born to HIV positive women, HIV positive children and adolescents receiving care in a clinical service outlet. HIV pediatric care will be implemented according to the PCIME strategy. Training in collaboration with PNSI will be conducted which includes modules and trainers. PCIME training sessions will be done for both healthcare providers and community counselors. Pediatric care and support is realized on 34 health districts. Children coming from PMTCT services will be tracked at multiple levels while they visit health facilities (immunization weighting dieting pediatric consultation, etc) as a result of healthcare staff training completed in pediatric care for the infected. The mother and pediatric health booklet will be an essential tool in rolling out the active search strategy. The reference and counter reference chart in the Ivorian health system will be adapted to improve the link between PMTCT services and pediatric care services to decrease the delay for exposed children to be put into care program. After delivery, the child will be systematically referred to pediatric HIV care service for monitoring and early infant diagnosis by means of the DBS technique. The ACONDA program will reach more than 80% of 2787 infants born to HIV positive women and continue to improve best management of PCR results so that to identify early HIV positive children and to start ART treatment. Children testing HIV positive will be followed up and those eligible for ARV treatment will be cared for in a comprehensive approach including not only ARV drugs but also cotrimoxazole, nutrition, vaccination, pear water, sanitation, hygiene and other care services. SCMS will give cotrimoxazole, pastilles for water purification, and insect treated nets including in care and support package. Nutritional education will be organized in care service outlets for parents in order to teach them good habits and new reactions with food. These sessions will be handled by site staff (trained MD, nurses, midwives). The pediatric nutritional monitoring will be done: regular weight and height taking to evaluate the pediatric nutritional state. Children will receive food kits in partnership with the PNN and PATH. The creation of a pool of adolescent leaders identified in health centers and sent to communities as peer educators will be undertaken to sensitize other children and youngsters. For PwP, new procedures targeting HIV-infected teenagers will be elaborated and provided to the health workers at sites level with the appropriated tools. Activity supervision will be done by ECD and Aconda from activity reports and periodic visits. Results of the evaluation will allow us to modify the strategy where needed. Quarterly based supervisions will be led by ECD members according to the national HIV/AIDS activity supervision document setup by PNPEC. Supervision visits by PNPEC and regionally will occur twice a year. National tools will be used for data collection and reporting will be done according to the network established between service outlets, the district and DIPE.

HIV Testing and Counseling (HTC) activities are realized on 9 health regions which are Lagunes I and II, Bas Sassandra, Haut Sassandra, Fromager, Lacs, Denguélé Bafing, Moyen Cavally and 18 Montagnes. At the end of September 2011, 98.2% of all patients including TB/HIV in 135 CT services and 103.9% of all pregnant women in 103 PMTCT services supported by Aconda have received CT. Aconda has obtained in health facilities 108172/110188 individuals who received HTC (including TB, pregnant women and infants) and 103843/104677 individuals who received HTC and their test results; in ANC settings 64692/64105 pregnant women who received HTC for PMTCT and 58861/57556 pregnant women who received HTC for PMTCT and their test results , in TB clinics, 3485/5760 TB patients who had an HIV test result recorded in the TB register. HTC activities based on PICT approach and finger prick, already implemented on 110 sites will be assessed to identify the gaps to be achieved. Aconda will take an active part in the promotion of the new testing algorithm with other partners. That simplified technique, will give us the opportunity to test patients at any stage of the health circuit. Trained CC will provide HTC according to national standards and the use of national HTC data collection tools. Each HIV positive patient relative like partners, children and parents will be encouraged to be tested in a proactive family testing procedure. The other way round, for each tested HIV positive child in the pediatric service, parents and brotherhood will be invited to take HTC in addition to EID. For couples HTC, Health actors and CC will be train to propose HIV testing to the both partners. Advantage of this strategy is to facilitate the follow up of the PLWHA (disclosure, observance of the therapy and continuation of care will be easier). Each PLWHA tested by a care provider will be referred to CC to reinforce information on HIV/AIDS, that patient will receive counseling based on a risk reduction plan which is also based on AB. The PLWHA will follow the HIV care circuit as defined and will be offered a comprehensive care (medical, TB, PwP, STI, care and support including nutritional and other support as needed). People tested HIV negative will receive appropriate counseling according to the AB and will establish a risk reduction plan with assistance from CC. An appointment will be given a control 3 months later. Patients, who are tested HIV positive in community or during mass HIV Testing campaigns, organized during various events, will receive a reference and counter reference form. The patient will be accompanied by a CC who will contact him with the CC on site. From that moment, PLWHA will integrate the health center HIV patients circuit. The counter reference part of his form will be filled in by the CC on site and given to the accompanying CC who will take it back to the campaign organizing NGO/CBO. That procedure will permit a significant reduction of the lost to follow up patients and facilitate their tracking down within the community for better follow up. About 10% of our testing activities will be done in community. HTC extension outside of health facilities will consist in using CC for a Door to Door. The nursing staff exposed to Post Exposure Prophylaxis (PEP) and all victims, national procedures related to use of ART must be applied at the most 48 hours after

PMTCT services will be re-enforced in 103 existing sites focusing on quality of services aspects. Forty new sites will be set up only in supported districts based on local needs and the area coverage level. The elimination of mother to child transmission of HIV requires strengthening of all existing and new sites including at least one service related to reproduction health. To enhance the frequency of visits to the site by pregnant women and follow up of those with HIV, CC will be reinforced in terms of training and logistics in order to make sensitization on PMTCT routine practice. All health providers involved in motherhood and gynecology care provision will be trained in the prevention curriculum package with national recommendations and procedures. All these trainings will be done using national modules. Based on the PICT approach and finger prick testing, all pregnant women will be checked at various points of service within the health facilities. HIV positive pregnant women will be tested for CD4 and referred to the ARV services to undergo treatment if eligible. Their partners will be systematically proposed to be tested and placed in care if HIV positive. In collaboration with ENGENDER HEALTH, a pilot project set up at 3 sites, will improve the involvement of the partners of female clients follow-up based on use of the Men As Partners approach. After the pilot phase, it seems necessary to evaluate the approach and to promote and implement good practices at other sites. Aconda will contribute to reproduction and dissemination of Mother and child health notebook, after validation. Health care providers will be trained for the use of the new Mother and child health notebook, which will be applied to improve the link between PMTCT and pediatric care. Non-eligible HIV positive pregnant women for ARV treatment will be provided with counseling and prophylaxis kits. CC will help and educate 85% of HIV positive pregnant women in how to take ART drugs for PMTCT at the health center and in their communities. Newborn children will be referred to pediatric units with their mothers HIV status noted in the Mother and child health notebook. They will be monitored for the HIV early diagnosis using the DBS method. The HIV-positive mothers and their children will be checked for nutritional status and provide with food and nutritional support if necessary. CC will monitor the infected pregnant women in their communities by home visits, auto-support groups activities and the integration of HIV positive women in their family and community. In the routine prenatal services, CC will provide individual counseling, psychological support and will collect data related to HIV testing. Without taking pregnant womens partner testing in count, the unit cost per patient reached with PMTCT in COP10 was $ 14.38 and in COP12 we will get down to $ 12.09. District PMTCTs focal point will mentor the new trainees. To be efficient at the district level coordination meeting will be organize to harmonize the intervention. Quality team will be created at each site and will be managed by the quality PMTCT focal point at district level. The Aconda team will provide the local stakeholders, including the district team, with technical assistance. Data will be collected and managed using the package of National tools at each unit of PMTCT activities. Care providers will be trained and supervised on consistent use of these tools..

ARV prescription is realized/offered in 9 health regions: Lagunes I and II, Bas Sassandra, Haut Sassandra, Fromager, Lacs, Denguélé Bafing, Moyen Cavally and 18 Montagnes. At the end of September 2011, Aconda has contributed to have 34 health districts provide 107 ARV services for 6733/6733 adults and children with advanced HIV infection newly enrolled on ART; 17377/22440 adults and children with advanced HIV infection receiving ARV therapy and 39889/42119 adults and children with advanced HIV-infection who started on ART. Forty new sites will be set up only at supported districts in order to increase access for ART services. Outlets opening, site meetings, trainings, supervisions, monitoring and evaluation are some services organized by Aconda in close collaboration with the ECD. Support will be given to physician through periodic sessions of group prescriptions, group therapy and phone calls. We will use a database to follow all PLWHA enrolled in health facilities supported by Aconda. Items which will be used include: clinical stage, CD4 level, and delay to ARV prescription. Every month, SI services present patients records for the newly enrolled on ART. The control of data quality will be based on national ARV standards to confidentially conform ARV prescription. Sites with more than 5% non-confirmatory ARV prescription will receive coaching support. These supportive activities will be done in order to notice ARV prescription indications and to reduce default prescriptions early which is feasible when all clinical, biological, community data in the program is monitored. ACONDA priority action will consist of delivering service outlets with paper tools validated by DIPE with regard to the national electronic tool SIGDEP. At the site level the role of AMD will be enhanced. They will be more involved in a critical feedback loop by generating activities reports and leading monthly meetings with health workers teams to discuss cases and findings. At district level a unique SI unit, CDGIS, will be setup. The data collection from sites with manual tools will be re-enforced and the data transmission to the DIPE will be improved using internet-based network. The unit dedicated to HIV activities data management, CATSIS, will be re-enforced to be more efficient. Among PLWHA, process to put eligible patients on ARV treatment according to national guidelines will be monitored at health facilities supported by Aconda. Side effects reported by clients will be supported by ACONDA under the leadership of the DPM. Side effect forms will be handled in the centers pharmacies; pharmacy staff will be trained and monitored in all the ART prescription centers. PLWHA on ARV therapy will receive care and support services. Cotrimoxazole, pastilles for water purification, insect treated nets, hygiene, PwP, psychology consultation and therapeutic food for malnourished patients will be given to them. $ 7500 is provided for policy, tools, service delivery and commodities of nutrition. Tuberculosis screening among PLWHA will be included systematically at each following visit. Links will be done with STI consultation, MCH and FP services. The monitoring of preventive activities and PEP related to blood and biological fluid exposure will be effectively completed at 114 existing Care and Treatment sites and 46 new sites.

The Ivoirian NGO ACONDA works to build Ministry of Health and AIDS (MSLS) capacity to expand access to quality comprehensive HIV/AIDS prevention, care, and treatment while contributing to sustainable service delivery and attainment of national strategic plan targets in nine regions of southern, western, and northwestern Côte dIvoire.

ARV pediatric prescriptions are provided in 9 health regions: Lagunes I and II, Bas Sassandra, Haut Sassandra, Fromager, Lacs, Denguélé Bafing, Moyen Cavally and 18 Montagnes. By September 2011, Aconda contributed to 34 health districts scaling up ARV services to reach 193/536 children with advanced HIV infection newly enrolled on ART; 1276/1796 children with advanced HIV infection receiving ARV therapy. The pediatric ARV therapy will be reinforced for at least 10% of children enrolled in the program. Key difficulties in ARV pediatric prescription stem from the lack of trained physicians in this technical area, and identification of a high number of newborns with HIV remains a challenge. Linkages across PMTCT and pediatric HIV treatment services will decrease the delay for exposed children by using mother to child notebooks. Tracing of children coming from PMTCT services will occur when they visit health facilities (immunization weighting dieting pediatric consultation, etc.) After delivery, we will reach more than 80% of 2787 infants born to HIV positive women for monitoring and early infant diagnosis, the DBS technique. We will improve management of PCR results to ensure HIV positive children start ART treatment sooner. Children who test positive will be followed up and those eligible for ARV treatment will be cared for in a comprehensive approach including ARV drugs, cotrimoxazole, nutrition, vaccination, pear water, sanitation, hygiene and other care services. SCMS will give cotrimoxazole, pastilles for water purification, and insect treated nets including in care and support package. Nutritional education will be organized in care service outlets for parents in order to teach them good habits and new reactions with food for children. Tuberculosis screening among children will be included systematically at each following visit. Links will be done with, mother and child health services, nutrition services and OVC programs in the community. Forty new pediatric HIV treatment services will be extended to all Aconda supported service outlets and the pediatric care guidelines by PNPEC will be available. The ARV drugs will be prescribed and given to children eligible according to national guidelines and side effects documented. For eligible children with CD4 equal or under 25%, ARV drugs in pediatric formula are available in all pharmacies. Adolescents passage to adult HIV treatment services is often initiated by the announcement of HIV status from a psychologist and trained CC. A health system network that links referring pediatricians and referring physicians for adult care is the overall aim with methodological support given through physicians periodic sessions of group prescription, phone contacts and therapy. We will use a database to follow children enrolled in health facilities supported by Aconda. The control of data quality will be based on national ARV standards. Sites with more than 5% non-conformity to ARV prescription will receive coaching which will be done in order to reduce default prescription. Priority action will consist of delivering service outlets with paper tools validated.