Fondation Ariel, a new Ivoirian NGO created as part of the Track 1 ART transition, aligns its goals with national objectives and principles of the Global Health Initiative. To strengthen Ivoirian capacity to sustain accessible high-quality HIV/AIDS services, Ariel will work to 1) to strengthen the capacity of Ministry of Health and AIDS (MSLS) health district management teams (DHMTs) to plan, budget, monitor, and evaluate quality HIV services, with the aim of progressive country ownership; 2) to collaborate with the MSLS to offer HIV/AIDS services, and 3) to build Ariel institutional capacity to sustainably implement HIV programs and become a strong Ivoirian actor in the national response to the HIV epidemic. Ariel will base interventions on a systemic approach to health systems strengthening, using a district approach to build sustainability and prepare for effective transfer of skills. At the health facility level, Ariel will support the MSLS to provide a full range of HIV/AIDS prevention (PMTCT, testing and counseling, sexual prevention), care (including OVC care), and treatment services in 29 departments in seven regions of southern Cote dIvoire.

Co-location of services will contribute to cost-efficiency. Ariel will focus its M&E strategy on strengthening the capacity of sites and districts to produce data using national tools, supporting districts on data management and annual data quality audits, and support for data use and analysis at site, district, and regional levels.

Vehicles:

Through COP11: 0

New in COP12: 3. One ($60,000) will be used by N'Zi Comoé Region for routine supervision, including of project activities; 2 ($100,000) for Ariels Abengourou and Abidjan offices for routine project activities and monitoring.

Total for life of mechanism: 3.

Ariels goals have been developed to be consistent with national objectives and Global Health Initiative principles by strengthening national capacity to sustain access and availability of high quality adult care and support in Bas-Sassandra, Nzi-Comoé, Moyen-Comoé, Zanzan, Agnéby, Lagunes1 and Lagunes2 regions. The targets are to reach about 49,000 adults in care at 218 sites in FY 2012 and 101,700 adults at 254 sites in FY 2013.

Ariel will strengthen adult care and support activities at site level through a district approach to joint planning, management, and supervision. Ariel will offer a basic package of care and support in accordance with national guidelines and in collaboration with other PEPFAR partners. Ariel will promote the use of social workers who participated in PEPFAR-supported pre-service training program to help with pre- and post-test counseling and to provide or refer to needed psychological, social, and spiritual support, OVC care, and other support, in close collaboration with community workers.

Ariel will progressively establish routine patient readiness consultations for ART to improve patient retention and reduce morbidity and mortality. Patient literacy programs will also be offered. Pre-ART patients will be managed to prevent them being lost to follow-up (LTFU). The patient flow in each site will be analyzed to ensure linkages with other services (maternal-child health (MCH), family planning) and to ensure that all patients benefit from the basic care package. Cotrimoxazole prophylaxis will be offered to all patients in need. The program will stress palliative care to ensure that health care workers effectively implement these directives.

Ariel will ensure linkages with other support, such as bed nets from the national malaria program and water purification tabs. Ariel will work with the national traditional health program to involve traditional healers in the management and referral of some ART patients who are LTFU.

All five components of Prevention with Positives will be implemented in each site. National tools will be used to train and monitor health staff and community workers.

Ariel will emphasize quality assurance and improvement (QA/QI) and retention in care. Ariel will conduct a rapid quality assessment via district quality committees and implement corrective measures during joint supervision as necessary. As part of QI in supported districts, Ariel will assess retention site by site. Ariel will focus on prevention of LTFU by improving organization of care in each site, by defining a simple and easy patient flow, and by reducing turnaround time. Ariel will improve management of patient appointments with electronic or paper-based systems and phone calls. The aim will be to increase retention to 80% within 12 months.

Based on evidence from a Food by Prescription pilot, Ariel will collaborate with the National Nutrition Program and other partners to provide food and nutrition support for eligible patients. To improve health worker motivation, Ariel will encourage merit recognition linked to results.

Ariel will facilitate and support a national strategy to promote cervical cancer prevention based on evidence.

In Côte dIvoire, the TB/HIV co-infection rate is over 24% for TB patients in the majority of TB treatment centers. WHO and UNAIDS have called for a reduction of 50% in TB-related deaths among people living with HIV/AIDS (PLWHA). Ariel takes this call seriously and will continue to collaborate closely with the national TB program (PNLT) and national HIV program (PNPEC). Ariels aims are to increase the HIV testing rate of TB cases from 75% (2009) to 90%; to intensify TB detection among PLWHA; and to intensify TB infection control. Ariel will work in health-care facilities in Lagunes1, Lagunes2 Agnéby, Bas-Sassandra, Nzi Comoé, Zanzan, and Moyen Comoé regions to test at least 4,909 TB patients for HIV at TB centers and to be providing ART for at least 1,178 co-infected patients as of September 2012.

Efforts will be made to meet program challenges, including follow-up of co-infected patients after TB recovery; integration of TB management at care and treatment sites; TB management for HIV-positive children; and infection control. Ariel will accomplish this through:

Dissemination of validated tools that capture TB screening of PLWHA, in collaboration with Measure Evaluation, the PNLT, and PNPEC; health-care workers (HCWs) will be trained to use the tools properly.

Building HCW capacity to perform basic TB symptom screening using the national tool and provide adequate referral for diagnostic work-up; this will be accomplished through training, onsite coaching of clinical staff, ensuring availability of forms, and enhancing reporting of this activity.

Using onsite training, reinforcing provider-initiated testing and counseling and fingerprick testing at TB centers to ensure that 90% of TB cases are tested for HIV.

Working with community health workers (CHWs) at large TB centers (CATs) to reinforce the directly observed treatment strategy (DOTS) for both for TB and ART. CHWs will stress the need for strong treatment adherence and will manage appointments to prevent loss to follow-up in both programs. Providing positive dignify, health, and prevention services to TB/HIV patients will remain a priority.

Provision of a mentoring plan for all pediatric centers providing care and treatment to HIV-positive children in order to provide TB screening and appropriate use of referral systems to prevent and treat children.

Strengthening TB control and multi-drug-resistant TB prevention activities in collaboration with the PNLT.

Better organization of care through activities such as separating patients with coughs from others and providing staff with protective equipment.

Ariel will maintain close collaboration with the PNLT by organizing quarterly joint supervision visits to the catchment areas of each of the CATs, according to a validated collaboration plan. One area of focus will be improving the timeliness of data reporting and data quality within the PNLT. In addition to joint supportive supervision, Ariel will perform routine data quality assessments to identify weaknesses and implement corrective actions with site staff. Technial assistance and logistics support will also be provided.

Ariels goal of strengthening pediatric HIV/AIDS care, in line with national objectives and Global Health Initiative principles, will be pursued by increasing the proportion of patients in care who are children from 6% to 8% and increasing the rate of child retention to 85% retained after 12 months in care. Interventions will take place in Bas-Sassandra, Nzi-Comoé, Moyen-Comoé, Zanzan, Agnéby, Lagunes1, and Lagunes2 regions and will reach at least 8,846 children receiving at least one care and support service by September 2013.

For this technical area, the district approach will be mixed with direct and strong support from experts at the Societé Ivoirienne de Pédiatrie (SIP). Eight pediatric care sites with high potential will be mentored by an expert at SIP to provide technical assistance (TA) on a monthly basis. These sites will receive the support of psychologists to take into account the specific needs of pediatric patients, including time for their HIV disclosure and moving from pediatric care to adult care and support. With the national TB program (PNLT), focus will be put on TB screening and treatment among HIV-infected children. In collaboration with the national malaria program (PNLP), Ariel will strengthen malaria prevention and treatment for children under 5 years through bed net distribution and application of national guidelines. Ariel clubs (support groups for children) will be established to increase retention and facilitate dialogue. For each of these sites, annual objectives will be set with the health care team.

Community groups will manage the appointments of new enrollees and plan all details for visits, taking into account school needs and mothers time constraints, to facilitate good retention of pediatric patients in care. Community groups will be proactive in looking into and preventing potential cases of loss to follow-up.

All supported care and treatment sites will benefit from:

1) Training and mentoring of doctors or nurses in charge of pediatric care to ensure that the new WHO guidelines validated by PNPEC are being implemented

2) Supervision with regional pediatric experts under the leadership of the district health management teams (DHMTs)

3) Scale-up of pediatric care to 80% of care and treatment sites to allow for care and treatment of children in the same location as mothers and reinforce the pediatric care network

4) Building skills in pediatric care in maternal-child health settings to create strong linkages between the two services and improve early identification of exposed children. The new mother-child health card will be helpful in these efforts.

Ariel will ensure that PCR testing is available in all supported districts and sites. Turnaround time for test results will be reduced with the involvement of the CDC/Retro-CI lab branch.

Based on evidence from a Food by Prescription pilot, Ariel will collaborate with the national nutrition program and other partners to contribute to food and nutrition support for eligible children. At participating sites, care providers will be trained on nutrition and be able to screen and provide nutrition counseling and treatment according to national guidelines. Emphasis will be put on cotrimoxazole prophylaxis for children in all sites to reach at least 90% of eligible children.

During quarterly meetings with DHMTs, half-day trainings on pediatric care will be held, and presenters will be asked to present achievements in pediatric care.

HIV testing and counseling (TC) is an essential entry point to care and treatment. Ariel will support routine provider-initiated testing at support health facilities and will focus on improving the following areas of TC: pediatric testing, couples testing, and pre- and post-test services to prepare those testing HIV-positive for care and treatment (with AB-oriented prevention counseling for those testing HIV-negative). Activities will take place in health settings in Lagunes1, Lagunes2, Agnéby, Zanzan, Bas-Sassandra, Nzi Comoé, and Moyen Comoé regions, which have a combined population of about 8.7 million and HIV prevalence estimated at 3.4%. During FY 2012, Ariel aims to test and counsel 378,000 people (including pregnant women in PMTCT settings), of which 10%-20% will be children.

The following activities will be undertaken to increase pediatric testing rates:

Testing children of adults in care and treatment programs through the use of standard operating procedures for identification and with assistance from community health workers (CHWs) or social workers.

Testing children via PCR/DBS at other entry points to care, such as immunization sites, nutrition centers, and social centers.

Testing children in pediatric wards (inpatient and out) by PCR/DBS or HIV rapid test according to age.

Continuing PCR testing in PMTCT settings; training nurses and midwives to be able to perform fingerprick testing.

Ariel will integrate TC at TB centers, with a focus on large treatment centers (CATs), the pneumology wards and emergency rooms of the University Teaching Hospitals of Cocody and Treichville, and the two largest sexually transmitted infection (STI) centers in Côte dIvoire. TC will also be introduced in regional and general hospitals in supported regions. This activity will be closely monitored to determine the proportion of patients testing positive.

Ariel will continue EGPAFs support for inpatient and outpatient consultations in all supported health settings, and a referral system will be put in place to follow up on those testing positive. Couples consultations, especially in ANC, will be encouraged, particularly with outpatients in collaboration with EngenderHealth and according to national guidelines. For those already tested, CHWs and social workers will assist in encouraging partners to come in for TC.

Ariel will contribute to National Testing Day through logistics support and technical assistance. Ariel will provide training and joint supportive supervision visits with district health management teams (DHMTs). Ariel will help develop a checklist to assist the lab quality focal point in monitoring the quality of TC offered, as well as fingerprick practices.

Community groups will be supported to promote TC in catchment areas of health-care institutions they work with. Social worker assistance will allow for more in-depth work during the post-test period, as well as care for discordant couples to mitigate social consequences such as stigmatization.

In collaboration with the General Directorate for Public Hygiene and other PEPFAR partners, Ariel will contribute to hospital waste management.

National tools will be used to capture TC data. Data use sessions will be organized through quarterly district meetings, and joint supervision visits with DHMTs will allow for continuous improvement at sites.

Ariels goals and objectives have been developed to be consistent with national objectives and Global Health Initiative principles by strengthening national capacity to sustain access and availability of high quality PMTCT services in Bas-Sassandra, Nzi-Comoé, Moyen-Comoé, Zanzan, Agnéby, Lagunes1, and Lagunes2 regions. The target is to reach at least 185,000 pregnant women tested, followed by appropriate prophylaxis and mother-child care, at 277 ANC sites by September 2013.

Through the district approach, Ariel will strengthen PMTCT services at sites through joint planning, management, and supervision (district and Ariel staff).

At the national level, PMTCT coverage was 43% in 2009. Ariel will facilitate expansion within supported districts to reach 80% by undertaking the following interventions:

Putting in place a pediatric HIV elimination plan in each district by working with the district health management team (DHMT) and key stakeholders. This plan will be written in a collaborative way to promote country ownership.

Support the roll-out of the revised mother-child health card and implementation of the new national PMTCT guidelines, consistent with the WHO 2010 recommendations to ensure quality of PMTCT.

Promotion of community-based activities: In collaboration with other PEPFAR partners, community mobilization will be conducted to increase primary prevention and male involvement. One CBO per region will be funded that supports care of women who test HIV-positive and the exposed baby in order to maintain them in care until the end of the PMTCT process. In addition, Ariel will help identify community health agents in each village and to promote reproductive health services, follow-up of pregnancies, and delivery in health settings. The aim of this community mobilization is to enhance ANC attendance.

Promote advanced strategies for ANC and immunization programs: Nurses with motorbikes will be provided with fuel to cover the catchment area (5km around the heath facility) twice a month.

Facilitating finger-prick HIV testing in pregnant women in maternity and family planning and as part of integration of MCH and HIV programs.

Support national guidelines on PCR/DBS to improve early diagnosis of children and reduce turnaround time of results by using phone, email or fax.

Couples consultations will be encouraged to provide couples testing according to national guidelines.

Enhancing point-of-care CD4 testing for HIV-positive pregnant women (PIMA machines will be provided by SCMS): Nurses and midwives will be trained with national HIV care program to perform the CD4 test to increase the proportion of HIV-pregnant women with CD4 count from 54% to 65%.

Building more effective district ownership: Quarterly meetings will be held under district leadership to promote data use among health care workers and DHMT. DHMT members will be trained on HIV and PMTCT to facilitate high quality supervision. Supportive supervision will occur jointly every two months at each big site and quarterly at the smaller ones to correct weaknesses.

Ensuring PMTCT patient flow is relevant, simple and integrates ANC, delivery, immunization, family planning, maternal-child health, nutrition, and links to treatment to reduce loss to follow-up.

Training for care providers will be supported to ensure high quality of PMTCT services.

With USG funding, Ariel will implement interventions consistent with national objectives and Global Health Initiative principles for adult HIV/AIDS treatment in 29 health districts of Bas-Sassandra, Nzi-Comoé, Moyen-Comoé, Zanzan, Agnéby, Lagunes1, and Lagunes2 regions. Ariel aims to support quality treatment in 117 sites serving 32,400 ART patients by September 2012. The district approach will be used to strengthen systems and improve quality of treatment through joint planning, management, and supportive supervision.

Recent ART site evaluation data show patient retention is decreasing over time, moving from 86% to 66% after 12 months on treatment. The same study showed a high level of incorrect regimens prescribed to HIV-2 patients. These data clearly show that quality of care is the major concern in ART programs in Côte d'Ivoire. Ariel aims to improve quality of care, as well as data quality, from site level to national level through the following interventions:

- Assessment of quality of care at each site through data collected under EGPAFs Project HEART, with an improvement plan designed and implemented with district and site quality committees.

- Analysis of patient flow in sites to reduce turnaround time and increase linkages with maternal-child health (MCH), nutrition, and family planning services. Task shifting to trained nurses will be implemented progressively in accordance with national policy to ensure equity in access to ART treatment. Sites will be encouraged to plan patient visits according to the patients itineraries, to put in place or improve a triage room, and to consult separately with first-time patients. Ariel will ensure that all care and treatment actors at sites are well-coordinated.

- The use of community members and social workers in sites to allow for better follow-up. To prevent loss to follow-up (LTFU), social workers will establish a follow-up agenda upon enrollment. Readiness consultations and adherence counseling will be established for new ART enrollees. Patients will be reminded of their appointments through phone calls. Each week, early LTFU patients will be contacted.

- Updated job aids to guide prescribers. Rapid training needs assessments will be done to adapt refresher training to respond to real needs in the field. Standard operation procedures (SOPs) on data use will be developed to help providers and district health management teams (DHMTs) analyze data.

- Improved management of ARV side effects and treatment failure through training and logistical support for transporting viral load samples from sites to referral lab according to national guideline.

All activities will be set up and monitored through joint supervision by DMHTs and Ariel staff to facilitate capacity building of local health workers and promote local ownership. Ariel will ensure DMHTs are established, functional, and trained on topics related to HIV to perform periodic supervision. Routine data quality assessments will be performed quarterly, and data quality audits annually, to improve data quality.

Ariels strategy for pediatric care and treatment will complement the strategy to be implemented by EGPAFs Project Djidja. Ariel will work for better enrollment of infected children in at least 30 sites of supported regions: Lagunes1, Lagunes2, Bas-Sassandra, Zanzan, Moyen Comoé, Nzi Comoé, and Agnéby. Ariel will mix its approaches, using a district approach mainly for smaller sites at the peripheral level and direct support for national pediatric care experts for high-volume sites. Ariel will provide high quality ART to at least 3,033 HIV-infected children under age 15 as of September 2013.

Under pediatric treatment activities, the district approach will aim to identify regional or district pediatric care experts. Ariel staff and district health management teams (DHMTs) will organize joint supportive supervision visits to sites. Medical doctors and nurses involved in pediatric treatment will be coached to care for HIV-infected children according to national guidelines. This strategy will help increase the number of sites offering ART to children.

Simultaneously, Ariel will focus on building the capacity of health care workers in the eight highest-volume pediatric treatment sites. They will receive monthly mentoring from a Société Ivoirienne de Pédiatrie expert.

The following challenges will be addressed for pediatric treatment activities:

- Low number of children on ART: Ariel will facilitate the early identification of children in need of care by performing PCR tests and will work to reduce turnaround time for receipt of results by using email, phone call or fax. Ariel will implement the 2010 WHO guidelines for early treatment of children, through trainings and mentoring. Active follow-up on exposed children will be undertaken in immunization clinics, nutrition points, and pediatric wards. The new mother-child health card will be helpful in these efforts. Procedures will be implemented to test children within adult ART programs. Each site will be assigned a number of children to be put on ART according to their level of capacity.

- Quality of care in pediatric ART sites: Checklists for joint supervision visits of DHMTs and Ariel technical officers will be provided to ensure the entire basic package of services is offered to HIV-infected children, including CD4 cells count, viral load, cotrimoxazole prophylaxis, TB screening, nutritional support, and support for prevention with positives. In addition, Ariel will support blood sample transportation from sites to referral labs for obtaining childrens medical exam results by a network lab. Appointments will be planned with social workers to prevent children from being lost to follow-up. Child-friendliness will be emphasized in large sites; measures will include smaller chairs and tables and toys and books in waiting rooms. Ariel clubs (support groups for children) will be established or reinforced in these sites.

- Data quality and use: Routine data quality assessments (RDQAs) will be conducted in pediatric sites for data quality improvement. With DHMTs, quarterly data review meetings will be organized. Procedures will be put in place to analyze pediatric data and take corrective action when necessary. These meetings will emphasize ways to increase the proportion of patients on ART who are children. Half-day trainings will allow updates on best practices in pediatric care and treatment to be exchanged among sites.