Cote d'Ivoire is facing a dual epidemic of HIV and tuberculosis, with an HIV prevalence rate among adults of

4.7 % (AIDS Indicator Survey, 2005) and a TB prevalence of 108 cases per 100,000 residents (MOH/PNLT,

2006).

The Ministry of Health (MOH) has received $3.8 million and €5.5 million under Global Fund Rounds 3 and 6

to strengthen its TB-control program. With Global Fund assistance, the National TB Program (PNLT) is

decentralizing sputum smear microscopy by increasing the number of designated TB centers, improving

human capacity by training health-care workers, developing and producing monitoring and evaluation tools,

and strengthening supervision. The number of sputum smear microscopy centers will be increased from 92

(currently) to 105 centers by the end of FY08. Anti-TB drugs are provided by the Global Drug Facility.

With USG support, the PNLT has taken the lead in the response to TB/HIV co-infection, along with the

National HIV/AIDS Care and Treatment Program (PNPEC), the Institute Pasteur of Cote d'Ivoire, and

others, working with EP implementing partners (EGPAF, ACONDA, and Alliance) to expand TB/HIV

activities throughout the country. The PNLT's response to the TB/HIV epidemic is focused on policies and

guidelines promoting the development of an TB/HIV collaborative framework, improvement in diagnosis of

TB among persons living with HIV/AIDS (PLWHA), provision of routine HIV counseling and testing of all TB

patients, and integration of HIV care and support in all TB clinics.

PNLT used EP support in FY04 and FY05 to expand services and improve supervisory activities. With FY07

plus-up funds, the PNLT is working with the PNPEC to develop national TB infection-control guidance and a

training curriculum to be used to promote better TB infection-control practices at all national TB and HIV

care and treatment facilities. A TB screening tool is being developed that will be used in all nationally

recognized HIV care and treatment facilities for systematic intensified TB case finding. With the FY07 EP

support and technical assistance from the American Society of Microbiology (ASM), the PNLT is expanding

availability of rapid liquid TB culture (using MGIT technology) at four facilities in and around Abidjan. The

PNLT will support storage and transportation of sputum specimens from all national TB diagnosis and

treatment facilities, including 11 CATs (stand-alone TB care and treatment facilities) and 81 CDTs (TB

facilities integrated into general district hospitals), to three of the four culture facilities (Institute Pasteur-CI at

the University of Cocody, Institute Pasteur-CI at Adiopodoume, and Cedres Lab in Treichville). This effort

will include development of a manual of standard operating procedures as well as tools for collection,

storage, and transportation of sputum specimens and procurement of storage (i.e. refrigerators) and

transportation equipment for 10 of the nation's 11 regional TB clinics. The smear-microscopy package

developed by CDC/WHO will be adapted and rolled out for training and retraining of lab technicians.

In FY08, the PNLT will work with all EP implementing partners to strive for HIV testing of 100% of TB

suspects and 100% of TB patients (~21,000) at all nationally recognized TB clinics. The PNLT will

strengthen referral systems and linkages between TB and HIV care sites to ensure that 100% of co-infected

TB/HIV patients are given cotrimoxazole prophylaxis and are enrolled in HIV care. All patients receiving

care at HIV care and treatment sites will be systematically screened for TB and referred to TB sites for

treatment. Priorities for FY08 will include:

TB/HIV coordination

- Collaboration between the national TB (PNLT) and HIV (PNPEC) programs will be strengthened by

developing a national TB/HIV coordination committee and ensuring joint planning of TB/HIV activities.

- Planning and implementation of TB/HIV activities will be promoted by establishing TB/HIV coordination

mechanisms at the district level.

- Quarterly meetings will be organized with TB/HIV partners to plan and review progress of TB/HIV

activities.

- The PNLT will support supervisory activities for monitoring of TB/HIV activities from the national level.

Expansion of provider-initiated HIV counseling and testing

- With support from CDC-CI, the PNLT will organize a training of trainers for rapid expansion of provider-

initiated counseling and testing in all TB clinics. EP implementing partners will draw on this pool of trainers

to scale up PITC in all EP-supported TB facilities.

- In collaboration with the PNPEC and EP implementing partners (EGPAF, ACONDA, and ICAP-CU), ARV

services will be made available at all CATs so that co-infected TB patients can be enrolled into HIV care

and treatment at the same facility.

Intensified TB case finding among HIV-infected persons

- With assistance from EGPAF, ICAP, and other EP partners, the PNLT will finalize the TB screening tool

and algorithm for intensified TB case finding among HIV-infected persons. The PNLT will work with the

PNPEC to incorporate the TB screening tool into the national HIV patient-encounter form.

- With assistance from USG partners, the PNLT will finalize its policy regarding INH prophylaxis among HIV-

infected patients.

Strengthening of laboratory capacity

- The PNLT will continue to support the collection and transportation of sputum specimens from all national

TB diagnosis and treatment centers, including the 11 CATs and 81 CDTs, to the three reference

laboratories for rapid TB liquid culture.

- With technical and financial assistance from the ASM and EGPAF, the PNLT will provide administrative

support for the continued expansion of the availability of diagnostic rapid liquid TB culture at three or four

additional TB facilities in the North and West of the country.

In consultation with CDC-CI and other EP partners, the PNLT will use liquid culture for diagnosis of smear-

negative TB. Cultures will be made available to all eligible patients free of cost.

With support from a national TB reference lab (Institute Pasteur-CI), the PNLT will continue to reinforce the

quality-assurance system, including external QA and on-site supervision, to ensure the quality of sputum

smear microscopy throughout the country.

Infection control

- Using the TB infection-control plan and a training curriculum developed with FY07 EP support, the PNLT

will work with implementing partners to ensure that facility assessments are done and TB infection-control

facility-level plans are developed and implemented by all EP partners.

Activity Narrative: TB/HIV surveillance

- Building on the Global Fund-supported modification of TB recording and reporting tools to capture HIV

variables, the PNLT will work with EP partners to ensure that these revised tools are available at all TB

clinics throughout the country.

- The PNLT will support reproduction and dissemination of TB recording and reporting tools to all CATs and

CDTs.

Other activities

- The PNLT will work with other EP partners to develop TB/HIV training materials to be used by all partners

to train staff at TB and HIV care sites.

- The PNLT will establish or strengthen communication between central and regional TB centers through

Internet and fax connectivity.

- The PNLT will enter into an agreement with REPMASCI (network of journalists and artists) to develop and

broadcast 10 radio spots for sensitization on collaborative TB/HIV activities.

- The PNLT will support a national TB/HIV Awareness Day to highlight the importance of TB/HIV co-

infection as well as ongoing TB/HIV activities around the country.

- In collaboration with Alliance and other partners, the PNLT will facilitate access of community-based

NGOs to CATs and CDTs in order to strengthen community-based support for TB and HIV patients.

- The PNLT will support an M&E plan tracking project-specific as well as EP and national indicators and will

report to the USG strategic information team quarterly program results and ad hoc requested program data.

To help build a unified national M&E system, the PNLT will participate in quarterly SI meetings and will

implement decisions taken during these meetings.

The Ministry of Health (MOH), through its Department of Information, Planning, Monitoring, and Evaluation

(DIPE), is responsible for HIV/AIDS data within the health sector. Effective management of strategic

information is a prerequisite for meeting the MOH objective of providing universal access to care and

treatment for PLWHA who need these services. As described in the 2006-2010 National HIV/AIDS Strategic

Plan and the National Monitoring and Evaluation Plan, having reliable information in usable form on time

(monthly, quarterly, and yearly) is critical for decision-making and rational scale-up of HIV/AIDS services.

Since 2003, the MOH has worked to reinforce the national health management information system (SIG)

using the Performance of Routine Information System Management (PRISM) conceptual framework

developed by Measure Evaluation and JSI. The MOH implementation of PRISM aims to (1) improve the

technical quality of procedures and tools for data management, (2) increase the individual capacities of

actors to understand and use data, and (3) improve the ministry's management practices using M&E data.

With FY06 funds, the USG supported strengthening of MOH capacities in monitoring and evaluation in order

to support the scale-up of HIV/AIDS activities (counseling and testing, PMTCT, adult and pediatric ART,

palliative care) under the National HIV/AIDS Care and Treatment Program (PNPEC). The MOH assessed

integration of HIV interventions by comparatively analyzing all CT, PMTCT, ART, and other HIV services.

Intervention sites of implementing partners and funding sources (JHPIEGO, MOH, SCMS, JSI, JHU/CCP,

EGPAF, Alliance Cote d'Ivoire, ANADER, CARE International, Abt Associates, FHI) have been studied as

well. Such assessments are designed to allow the MOH to develop a consolidated work plan for a better

repartition of HIV/AIDS activities in the health sector.

With FY07 funds, the MOH is working to:

• Develop training tools and promote performance standards in order to improve the management and

quality of trainings at central, regional, and district levels, with technical assistance from JHPIEGO.

• Advocate the computerization of data-management processes through the ministry.

• Provide SI-related equipment (computer hardware and software, printers, Internet connectivity) to the

DIPE and PNPEC.

• Train and supervise MOH human resources in M&E at the central and district levels.

• Conduct a sentinel sero-surveillance survey.

In FY08, based on lessons learned in FY06 and FY07, the MOH'S DIPE and PNPEC will:

• Set up a nationwide longitudinal HIV-positive patient-monitoring system using an adapted version of the

electronic system currently used by ACONDA.

• Assure reliability and validity of data collection by developing and executing a data-quality improvement

plan with technical assistance from external contractors and in close collaboration with district data

managers.

• Work with the PNPEC and other partners toward the use of unique patient identifiers as a way of following

patients through time and space.

• Reproduce and disseminate self-evaluation tools (for CT, PMTCT, and adult and pediatric ART) at 16 CT

sites, eight PMTCT sites, and six treatment sites, in preparation for an evaluation exercise.

• Disseminate computer kits and applications to nine regions (bringing coverage to all 19 health regions), in

accordance with the extension plan elaborated in 2007.

• Continue to train field providers in the use of data-collection tools. A semi-annual supervision visit will

follow these trainings.

• Continue the ARV resistance surveillance initiated in 2007.

• Continue the development and dissemination of reports, including a periodic newsletter/bulletin on

HIV/AIDS activities.

• Conduct operational research in health centers (on data control, quality of care, users' satisfaction) in

order to improve the quality of services when scaling up programs.

In all, FY08 activities will support SI training for 286 people.

The MOH will report to the USG strategic information team quarterly program results and ad hoc requested

program data. To help build and strengthen a unified national M&E system, the MOH will participate in

quarterly SI meetings and will implement decisions taken during these meetings.

Côte d'Ivoire is the country most severely affected by HIV/AIDS in West Africa, with an adult prevalence

rate of 4.7% (National AIDS Indicator Survey, 2005).In pursuit of the Ministry of Health (MOH) objective of

providing universal access to ART for all eligible PLWHA, the National HIV/AIDS Care and Treatment

Program (PNPEC) collaborates with other MOH structures to ensure coordination of health-sector HIV/AIDS

interventions through two main strategies: (1) integration and decentralization of HIV/AIDS and other health-

care activities and (2) implementation and enforcement of national policies, guidelines, norms, and

standards.

FY06 USG funding allowed the MOH to reinforce planning and coordination capacities at both the central

and decentralized levels, with the objective of scaling up HIV/AIDS interventions with technical assistance

from PEPFAR partners. With FY07 funds, the MOH:

- Reinforced national coordination frameworks through the development of a consolidated plan and

mapping of interventions;

- Reinforced local coordination bodies at the decentralized level in 10 of 19 health regions (18 Mountains,

Bas-Sassandra, Denguele, Haut-Sassandra, Lakes, Lagoons, Moyen-Comoe, Savannes, South-Comoe,

and Valley of Bandama);

- Strengthened the involvement and capacities of local authorities (mayors, presidents of general councils,

district governors), including through resource mobilization, in order to promote local leadership and

sustainability of the HIV/AIDS response;

- Led a human-resources assessment to inform development of a policy for the reinforcement of human

resources for health, including an activity implementation plan (in collaboration with Abt Associates);

- Coordinated the development of a twinning relationship between the National Public Health Laboratory

(LNSP) and the CDC/Retro-CI laboratory and worked to ensure that PEPFAR and Global Fund trainings are

complementary to facilitate tracking of progress and standardization of services.

In FY08, the MOH will use USG funds to work through central, regional, and departmental structures to

continue and strengthen interventions to improve planning, coordination, and capacity building for effective

scale-up of HIV/AIDS activities in the health sector.

A particular effort will be made to improve national coverage in HIV counseling and testing, PMTCT,

pediatric HIV/AIDS care, and antiretroviral treatment, with increased involvement of PLWHA and the

community. The MOH will document best practices and promote a standard of excellence at the district

level. To implement these activities, the MOH will engage technical assistance from national and

international TA providers.

To accelerate the process of decentralizing HIV/AIDS services, the MOH will update decentralized care and

treatment plans with a mapping of HIV/AIDS interventions in the health sector, including plans for integrated

care and treatment and the development of micro-plans in the nine remaining regions. The MOH will also

focus on the elaboration of a dissemination plan for all national documents related to HIV/AIDS care and

treatment. All interventions will be implemented in close collaboration and coordination with other partners,

especially Abt Associates, JHPIEGO, and EGPAF, in order to elaborate district models that can serve as

best practices and be easily replicated.

To improve coordination of health-sector interventions, the MOH will:

1. Ensure the reproduction and dissemination of directives, norms, and standards of quality of care (CT,

PMTCT, ART, pediatric treatment, palliative care);

2. Revise national care and treatment policies (clinical treatment, including pediatric treatment, as well as

CT, STI management, PMTCT, palliative care, drugs and other commodities, nutrition, and TB/HIV);

3. Revise norms, guidelines, and standards of quality of care for trainers in service delivery (trainer guides,

participant books, reference handbooks) in pediatric treatment, HIV rapid testing, PMTCT, CD4 count, and

STI management;

4. Organize quarterly, semi-annual, and annual coordination meetings of all actors implementing health-

sector HIV/AIDS interventions, along with meetings of the relevant working technical working groups (CT,

PMTCT, palliative care, treatment). Funds will also contribute to organizing National and World AIDS Day

activities in collaboration with the Ministry of the Fight Against AIDS (MLS).

The MOH will focus on the elaboration of quality-assurance tools and training materials and approaches (in

collaboration with JHPIEGO); evaluation of training effectiveness; assessment of training needs (in

collaboration with the Department of Training and Research (DFR) and the Department of Human

Resources (DRH)); the creation of a documentation center at the PNPEC; and the production and

dissemination of a quarterly journal on health-sector HIV/AIDS interventions. In addition, the MOH will

participate in national and international meetings to remain relevant and current on HIV/AIDS policies and

implementation.

The MOH will continue to implement an M&E plan tracking project-specific, PEPFAR, and national

indicators and will report to the USG strategic information team quarterly program results and ad hoc

requested program data. To help build a unified national M&E system, the MOH will participate in quarterly

SI meetings and will implement decisions taken during these meetings.