PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
"The International Center for AIDS Care and Treatment Programs at Columbia University Mailman School of Public Health (ICAP-CU) proposes to support the Ivorian Ministry of Health (MOH) to expand HIV/AIDS prevention, care, and treatment to 10 facilities in underserved regions of the country. Sites will be supported to provide an integrated package of prevention, care, and treatment services, including provider-initiated counseling and testing (CT), PMTCT, HIV care, antiretroviral therapy (ART), and TB/HIV integration. As this is a new program, the first five months will focus on critical start-up activities, such as hiring staff, establishing an office, developing agreements with the Government of Côte d'Ivoire, and identifying and preparing sites. Nonetheless, ICAP-CU anticipates promptly initiating services and enrolling patients at five of the 10 target facilities before the end of the fiscal year, with the remaining five sites to be launched in the first quarter of FY08. As ICAP-CU has yet to engage in detailed discussions in Côte d'Ivoire, this proposal reflects preliminary plans that we anticipate will be further developed and enriched over time in collaboration with CDC-CI and the Ivorian MOH."
Targets
Target Target Value Not Applicable Number of service outlets providing the minimum package of 5 PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and 1,250 testing for PMTCT and received their test results Number of HIV-infected pregnant women who received 94 antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT 30 services according to national and international standards
Table 3.3.02: Program Planning Overview Program Area: Abstinence and Be Faithful Programs Budget Code: HVAB Program Area Code: 02 Total Planned Funding for Program Area: $ 5,341,411.00
Program Area Context:
Background
The 2005 AIDS Indicator Survey (AIS) has provided critical information about the HIV/AIDS epidemic in Cote d'Ivoire, permitting better targeting of prevention and care efforts. Within an adult HIV prevalence of 4.7%, females in all age groups were far more likely than males to have HIV (6.4% vs. 2.9%). Male prevalence may be mitigated by near-universal (96%) circumcision. Geographic differences included marginally higher HIV prevalence in urban settings and marked regional differences, from 1.7% in the Northwest to 5.5% or more in the South and East and 6.1% in Abidjan.
Sexual debut was reported by age 15 for 23% of females and 10% of males, by age 18 for 71% of females and 48% of males. The population aged 15-49 reported that 5% of females and 31% of males had two or more sexual partners in the previous year; 33% of females and 58% of males reported a risky sex partner; and 66% of females and 48% of males did not use condoms with risky sex partners. While only 2% of men reported paying for sex, 31% of unmarried women aged 15-19 reported having a sex partner who was at least 10 years older. One-third of married women were in polygamous marriages.
HIV knowledge was low, especially among women who had no education, lived in rural areas, or lived in the North/West. Conversely, both high-risk behavior and condom use were more likely among better-educated, urban people who lived outside the North/West. Attitudes reflecting intolerance conducive to HIV stigma and discrimination were widespread, particularly among women. More than one-third (34%) of women reported having no access to any mass media.
FY06 Response
At national and local levels, Ivorian government response is marked by strong commitment and limited resources. The Ministry of the Fight Against AIDS (MLS), charged with coordinating all HIV/AIDS activities, in 2006 drafted a new HIV/AIDS National Strategic Plan for 2006-2010 that emphasizes behavior change communication (BCC) aimed at promoting abstinence, fidelity, partner reduction, and delay of sexual debut and at reducing HIV-conducive cultural practices and stigma and discrimination.
The USG-CI pursues a comprehensive ABC prevention approach emphasizing delay of sexual debut, partner reduction, stigma reduction, and gender equity. In 2006, the USG expanded public- and private-sector BCC interventions at the community level and in targeted high-risk populations. Projects also focused on reinforcing the roles of parents in influencing social norms that promote fidelity, encourage partner reduction, and address risk factors such as alcohol and drug use. The MLS established a BCC committee to improve quality, coverage, and coordination of BCC activities. A significant focus was to develop youth- and gender-specific prevention programs emphasizing life skills, gender equity, and prevention of gender-based violence. Emphasis was also placed on BCC capacity-building at central and decentralized levels.
FY07 Priorities
In 2007, the USG will reinforce and expand effective programs and introduce new interventions to reach both pervasive behaviors in the general population and specific subpopulations at greatest risk. Targeting of interventions will respond to available data, with continued concentrations in the urban South (Abidjan, San Pedro) and prioritizing of other high-prevalence areas through local sub-grants, selection of sites for life-skills and sports programs. AB components will target women and girls, emphasizing links to PMTCT and CT, and reach males with messages about gender equity and violence. Based on lessons learned, available data, and the national strategic plan, the USG will focus on the following AB priorities:
1. A locally appropriate response to address major sources of new infections. With BCC committee
attention to matching interventions and documented need, BCC campaigns will work to increase knowledge and safer sexual behavior in underserved communities (e.g. in the North and in rural areas) as well as in targeted subpopulations (e.g. sex workers, uniformed services, life skills for in- and out-of-school youth, stigma reduction and positive gender norms among religious leaders). 2. Expanded reach of BCC messages through mass-media and IEC campaigns. Mass media is both underused for HIV prevention and inadequately accessed, especially by women and in rural areas (AIS, 2005). The USG will place an increased emphasis on targeted mass-media campaigns linked to interpersonal outreach. Campaigns will be designed both to model positive behaviors (e.g. Miss Cote d'Ivoire promoting AB messages) and to create stigma around dangerous behaviors (e.g. cross-generational sex and gender-based violence in a TV/radio soap opera). Within a push for decentralization, programming will seek to reach subgroups lacking mass-media access through effective IEC dissemination such as at transit centers for IDPs, film projection and local-language radio in rural areas. 3. Strategies for delay of sexual debut and partner reduction. USG funding will reinforce and expand programs using church networks, schools, and sports programs to reach youth with abstinence and fidelity messages and life skills to improve risk perception and make safe sexual choices. The USG will also increase activities targeting adults in high-risk and general populations to enable better sexual choices and better communication with their children on subjects ranging from HIV transmission to male social norms. 4. Operations, qualitative, and quantitative research. To design more effective programming aimed at delay of sexual debut and partner reduction, more formative research is needed to understand how Cote d'Ivoire's crisis has shaped or reinforced risk behaviors. The addition of a behavioral scientist and the AIS data will allow field research to refine high-risk subgroup profiles and address questions such as why girls have sexual debut early, with older men and multiple partners, etc., and whether structural interventions can reduce vulnerability to cross-generational sex. 5. Support of local networks that influence community values. Networks of religious leaders, artists, NGOs, and PLWHA can play an important role in influencing behavior and sustaining effective interventions. USG funding will help build the capacity of leaders and members of these networks to promote AB and gender-equity messages and encourage safer sexual choices in their communities.
Coordination The USG is the major donor supporting AB activities in the country. Other partners focusing on child protection, gender violence, reproductive health, and gender issues include UNICEF and UNFPA. Key institutional partners include the ministries of AIDS, Education, Social Affairs, Health, and Youth, as well as PLWHA networks. Coordination with partners on the BCC committee and other sectoral and decentralized forums is improving.
Sustainability The USG continues to promote sustainability by building the capacity of indigenous organizations to implement programs and raise funds. The USG is transferring technical, financial, programmatic, and M&E skills from international organizations to local CBOs, NGOs, FBOs, and ministries to manage and be accountable for implementing activities and achieving results. This transfer is reinforced by USG emphasis on a district model of service delivery, on linking services (e.g. sexual prevention, PMTCT, ARV, and care), on public-private partnerships, on a new Ivorian umbrella organizations building capacity among indigenous new partners, and on support for religious and PLWHA networks.
Program Area Target: Number of individuals reached through community outreach that promotes 174,544 HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that promotes 647,286 HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention programs 6,737 through abstinence and/or being faithful
Table 3.3.02:
Target Target Value Not Applicable Number of clinic sites with associated CBO/FBOs providing community based services to persons coninfected with HIV/TB. Training in program planning, management and monitoring and evaluation for CBO/FBO in support of HIV-TB continuum of care Number of service outlets providing treatment for tuberculosis (TB) 5 to HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients given TB preventive therapy Number of HIV-infected clients attending HIV care/treatment 638 services that are receiving treatment for TB disease Number of individuals trained to provide treatment for TB to 100 HIV-infected individuals (diagnosed or presumed)
Table 3.3.08: Program Planning Overview Program Area: Orphans and Vulnerable Children Budget Code: HKID Program Area Code: 08 Total Planned Funding for Program Area: $ 7,387,758.00
The 2005 AIDS Indicator Survey (AIS) has provided critical information about the HIV/AIDS epidemic in Cote d'Ivoire, permitting better targeting of prevention, care, and treatment efforts. Adult HIV prevalence is estimated at 4.7%, with higher rates among woman than men (6.4% vs. 2.9%). Geographic differences included marginally higher HIV prevalence in urban vs. rural settings and marked regional differences, from 1.7% in the Northwest to 5.8% in the East and 6.1% in Abidjan. Sexual debut was reported by age 15 for 23% of females and 10% of males, by age 18 for 71% of females and 48% of males. Among unmarried women aged 15-19, 31% reported having a sex partner who was at least 10 years older.
The AIS estimated that 16% of children were OVC, including 8% who had lost father, mother, or both. OVC rates did not vary significantly by gender or urban/rural residence, but they increased markedly with age, from about 9% of infants to 25.3% of the 15-17 age group. OVC rates were lowest in the North (4.2%) and Northwest (7.2%) and highest in the South (18.4%) and in Abidjan (18.2%). UNAIDS (2004) estimated that 310,000 children had been orphaned by AIDS and 80,000 children were living with HIV.
Institutional and community-based services for HIV-affected families are limited, especially outside Abidjan. The country's extended politico-military crisis has disrupted social, health, and education services and economic activity, potentially increasing child vulnerability, and has resulted in significant decreases in donor funding for OVC. The World Bank (MAP) continues to delay assistance until issues such as disarmament are adequately addressed. The EP is the only major donor for OVC activities in the country.
With Emergency Plan (EP) assistance, Cote d'Ivoire has taken important steps toward ensuring OVC support through policy, coordination, capacity-building for NGO/CBO/FBOs, training of caretakers, and delivery of direct services to 18,000 children (March 2006). The overall objective at the national level is to reduce the vulnerability of 60% of children orphaned or otherwise made vulnerable by HIV/AIDS. Progress toward this objective is coordinated by the Ministry for the Family and Social Affairs (MFAS) and its National OVC Program (PNOEV) in cooperation with the national think tank on OVC (CEROS-EV), with technical assistance from FHI. Activities at the district level are coordinated through technical HIV/AIDS coordination committees/platforms. These groups have improved planning and coordination through the development of a national strategic plan (2003), the ministry's HIV sectoral plan, and a national OVC policy and M&E plan (2005). These documents clearly define the national priority of supporting OVC within their families and communities.
FY 05-06 Response
In FY05, the EP, Global Fund, and UNICEF funded the rapid expansion of sub-grants to CBOs and FBOs to support expanded decentralized services for OVC and their host families and communities. Based on the 2005 national OVC policy, standard criteria for services to be provided for OVC were developed in 2006 (to be validated in 2007). Identification of OVC is conducted by community committees, which provide an initial assessment to define needed services and household follow-up. A central part of the OVC strategy is building linkages that allow any child living in an HIV-affected household to receive comprehensive services, including pediatric HIV treatment if needed, with record-keeping to facilitate follow-up and integrated care.
In FY 05 and 06, the district pilot project of San Pedro was designed as a model for a network of linked social and health services (OVC, palliative care, VCT, PMTCT, HIV/TB, ART and STI treatment, etc,) in the public and private sectors within a geographic area. This model served to reinforce local coordination bodies, link district services to regional and tertiary referral and counter-referral structures, and strengthen the roll-out of HIV prevention, care, and treatment services.
Through FHI and Care International, the USG supported national authorities in conducting a national HIV survey with OVC-specific indicators and in conducting rapid mapping of OVC services. In 2005, a university-level OVC curriculum for social workers was developed, to be integrated into the academic schedule.
National and district systems strengthening and policy implementation. FY07 activities will work to translate the policy achievements of 2005-06 into high-quality, sustainable program services, with activities projected to serve 72,214 OVC. The San Pedro model will be implemented and evaluated in FY07, and based on its success, the EP will support expansion of the district network to additional pilot sites. The National OVC Program will lead efforts to promote human and legal rights for OVC, including training sessions on OVC rights and a review of laws and policies pertaining to OVC. With FHI and Measure/Evaluation support, the MFAS will continue to coordinate, track, and evaluate OVC activities and training programs. As part of a strong emphasis on improved quality of OVC services, each OVC sub-grantee will receive specialized training in OVC M&E, including in the use of standardized tools provided by the PNOEV for needs assessment, program M&E, quality assurance, and use of data for decision-making. The Public-Private Partnership TWG will support the development and piloting of income-generating activities for adolescent girls and families with OVC as a strategy for decreasing vulnerability and increasing sustainability of OVC care. A university-level curriculum will be designed to train teachers and community counselors in how to work with OVC.
Child-level direct services and community mobilization. New Partners Initiative recipients and a new Ivorian organization with a board of national stakeholders will support capacity building of local partners through OVC-specific sub-grants designed to expand community-level services nationwide. Through support groups and caseworkers, EP-funded partners will work to provide OVC with consistent, personalized support. With PEPFAR and UNICEF support, partners will launch aggressive household outreach to facilitate access to HIV testing linked to palliative care, PMTCT, TB treatment, and other HIV services.
Expanded referral systems to improve geographic and targeted population coverage. In coordination with PNOEV/MFAS, EP partners will provide sub-grants and technical assistance to local NGO/CBO/FBOs throughout the country, including in areas controlled by the Forces Nouvelles (North and West). In the North, the CARE International project will aim to develop referral relationships and systems with other EP-funded partners and regional service sites for the provision of TB treatment services, including treatment of active TB using DOTS for HIV-infected children, treatment for latent TB infection, and treatment of other severe illnesses. OVC will be linked to routine immunization and other programs through a system to link medical records for HIV-exposed and HIV-infected children with records at local health centers.
Coordination and M&E. The effective collaboration of the PNOEV team has facilitated the coordination and M&E efforts of the ministries responsible for education and health as well as EP-funded partners. These collaborations provide an effective platform to address the needs of OVC and their host families. In 2007, the EP will create a cooperative agreement with the WFP and UNICEF for piloted activities to provide nutritional support and food aid to OVC and their families.
Sustainability. The USG continues to promote sustainability by building the capacity of local NGO/CBO/FBOs to implement programs and mobilize funds and by transferring technical, financial, programmatic, and M&E skills from international organizations to local organizations and ministries.
Program Area Target: Number of OVC served by OVC programs 72,214 Number of providers/caregivers trained in caring for OVC 1,486
Table 3.3.08:
Target Target Value Not Applicable Number of individuals trained in BCC to promote treatment uptake Estimated number of individuals reached in mass media campaigns Number of service outlets providing antiretroviral therapy 5 Number of individuals who ever received antiretroviral therapy by 750 the end of the reporting period Number of individuals receiving antiretroviral therapy by the end of the reporting period Number of individuals newly initiating antiretroviral therapy during 250 the reporting period Total number of health workers trained to deliver ART services, 100 according to national and/or international standards
Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 2,280,555.00
Despite the crisis that has divided the country since 2002, Cote d'Ivoire still boasts a substantial technical cadre and well-developed infrastructure.
The national public laboratory system has three levels: the reference level with laboratories at the 4 University teaching hospitals, five specialized institutes including the National Public Health Reference laboratory (LNSP), the National Blood Bank (CNTS) and research centers; the intermediate level with 17 regional hospital and 68 district hospital laboratories; and peripheral level health centers with basic laboratory services. Private laboratories also provide laboratory services with nominal supervision and quality control by national authorities. Of the 1,300 health structures authorized to provide laboratory services less than 300 are operational, few provide all the services that they are mandated to provide and HIV testing and CD4 laboratory services were limited to Abidjan until 2004.
The reference level service package includes HIV and CD4 tests, biochemistry, hematology, TB and other OIs tests and may include viral load tests. Most regional labs at the intermediate level now provide HIV and CD4 testing, basic hematology (CBC), biochemistry and TB tests. The testing capacities at the district and peripheral level is extremely heterogenous. Links between the laboratories are weak and the supervisory system is poor. No EQA policy has yet been adopted.
There is an enormous challenge to provide decentralized quality laboratory services to match the rapid pace of scale up of HIV services. This is especially severe in some zones with dire human capacity constraints.
Former research labs (RETRO-CI and CEDReS) continue to perform most of the reference HIV testing, surveillance and assisting with the evaluation of new HIV test kits, algorithms and alternative blood collection methods. Of note, the LNSP does not do ARV drug quality assurance testing after drugs are registered with regulatory authorities.
Côte d'Ivoire also receives support from the Global Fund HIV and TB projects (UNDP is principal beneficiary) which has provided substantial equipment acquisition for laboratories continued into the 2nd project phase (2006-2008). WHO provides ongoing technical assistance from their offices as part of various HIV and health system initiatives. Clinton Foundation is also engaging in support of paediatric treatment with potential for an important laboratory component. The Global Drug Facility appears to provide some promise for TB related consumables for 2007. Axios provides Determine rapid test donations in support of the PMTCT program.
The prolonged politico-military crisis with changes in the government and restructuration of the MOH and national HIV care and treatment program has had a retarding influence on policy development, coordination and planning. With the establishment of new leadership at the MOH and national care and treatment program and the creation of a national laboratory commission these issues appear largely resolved moving into FY07.
The EP partners, Projet RETRO-CI, APHL, EGPAF, ACONDA and SCMS work in close collaboration with the USG team and the MOH to plan and implement EP supported laboratory activities.
With FY06 funds, quality laboratory services were provided at EP supported sites through a standardized package with trainings, laboratory needs assessment, assistance in initial testing and by periodic on-site supervision by trained staff.
Complementing substantial assistance as part of the Global Fund HIV and TB projects, EP partners currently support 22 of the 36 laboratories with the capacity to perform HIV and CD4 tests in country and
plan to support 11 more with FY06 funds. Of the 22, 7 laboratories are located at the reference level including LNSP, CEDReS and RETRO-CI, 13 at the intermediate level and 1 at the peripheral level. With FY06 funds, EP partners plan to support 7 additional at the referral level and 4 at the peripheral level. A pool of trained supervisors is being expanded at central and decentralized levels. A standardized supervision guide and laboratory assessment checklist has been developed. Improved commodities management at EP supported sites with strengthening of procurement, forecasting and stock management at central and peripheral levels is also underway.
EP partner Projet RETRO-CI provided HIV testing to complete the 1st national AIDS Indicator survey and regular national antenatal surveillance surveys. APHL and RETRO-CI hosted several other activities aimed at improving HIV and CD4 testing (including development of training and supervision materials and national and international trainings), the evaluation of CD4 machines, HIV testing protocols and simple test algorithms, setting up a network for inter-laboratory partnership, and putting in place norms and standards definitions to help compliance with international standards.
Various evaluations were performed to evaluate human capacity in the health sector: a national survey including public and private sector (Abt Associates); an evaluation of INFAS (APHL); and a review of existing laboratory training curricula (APHL, JHPIEGO).
COP 07 priorities include:
Expanded reference laboratory capacity within the LNSP and laboratory network through quality management training, development of Proficiency Testing and establishment of a national external quality assessment program for HIV testing.
Expanded human capacity through the creation of a national pool of decentralized trainers/supervisors and service providers. Integration of the laboratory technician curricula in preservice and inservice training at INFAS with a TOT approach to cover: HIV testing, biological monitoring of HIV infected patients (CD4 count), commodities management, record-keeping and quality assurance and biosafety as part of good laboratory management. Expansion of HIV testing by trained personnel outside traditional laboratory professionals will also be evaluated.
Direct support to service delivery with the ongoing decentralization of laboratory services with good laboratory practices at more than 200 PMTCT and VCT sites and laboratories serving more than 100 HIV and TB treatment centers.
Key strategic information activities will include longitudinal patient monitoring using biomarkers, antenatal seroprevalence surveys, HIV drug resistance as a part of the HIV treatment program evaluation, and evaluations of new test kits and HIV-related technologies. A number of pilot studies will be conducted to evaluate the feasibility and suitability of Dried Blood Spots (DBS) for DNA PCR for early infant diagnosis as part of the national program. Targeted evaluations (pending ethical approval) are proposed including rapid HIV tests on finger-prick whole blood, adapted rapid tests to improve detection of HIV and/or TB, and suitability and accuracy of DBS sampling method for genotypic testing.
SCMS will become the primary procuring agent for EP laboratory reagents and supplies. Quality assurance will be done for OI and ARV drugs through SCMS partner Northwestern University in South Africa. APHL and RETRO-CI will assist with technical specifications for equipment, commodities and maintenance. The online SCMS database of lab supplies will make ordering easier. SCMS will integrate lab supplies into commodity management tools and provide TA on the use of these tools. All existing treatment sites will be rapidly equipped, trained and supported to be able to generate regular, accurate commodities use, stock and needs reports using improved management tools.
The USG will work closely with its partners and other stakeholders to improve planning and coordination and sustainability through all of it's activities to promote networking, decentralize and integrate HIV services, build human capacity, and identify and use simplified adapted technologies.
Program Area Target: Number of tests performed at USG-supported laboratories during the reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 33 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 560
Table 3.3.12:
