Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has received USG funds to assist the

Ministry of Health (MOH) in supporting and expanding quality PMTCT programs while building on and

complementing other programs supported by PEPFAR, the Global Fund, UNICEF, and others. EGPAF

works to implement a family-centered approach in delivering care and treatment. Its PMTCT program will

support 120 sites and serve 100,000 women attending ANC services in FY07. (Seventeen sites previously

supported by EGPAF have moved to direct PEPFAR support through ACONDA.) The program has had

some notable successes:

• Provision of technical and financial assistance to update and disseminate the national PMTCT policy and

guidelines, including combination ARV prophylaxis and routine HIV counseling and testing (CT), and

support for the development of new training tools and materials.

• Successful introduction of a series of innovative approaches, including a district approach to broaden the

program's reach, dried blood spot (DBS) techniques for early infant diagnosis using DNA PCR, provider-

initiated "opt-out" HIV testing at most sites, rapid testing in labor and delivery, and use of complex ARV

prophylaxis regimens, including ART eligibility assessment of pregnant women and provision of ART where

eligible.

• Improvement of the quality of PMTCT services at all sites receiving direct support from EGPAF, achieving

better uptake at every level of the PMTCT cascade (CT, results, prophylaxis, and follow-up). At least 80% of

women tested are receiving their test results, and at least 90 % of HIV-positive pregnant women are

receiving ARV prophylaxis. EGPAF and its partners have also improved follow-up and strengthened

referrals to care for HIV-positive mothers and infants.

• Strengthened PMTCT monitoring and evaluation systems at the national, district, and site levels, in

collaboration with government and other key partners.

• Strengthened nutritional counseling by health workers for antenatal and postpartum HIV-infected women,

including counseling on breastfeeding cessation and culturally appropriate replacement foods at nine

demonstration sites, with support from EGPAF sub-partner PATH, Helen Keller International/Abidjan and

the national HIV nutrition technical working group.

• Use of performance-based contracting to support PMTCT programs, with development of M&E tools to

collect patient data, monitor program quality, and ensure correct reimbursement to sites for services

performed.

• Increased involvement in PMTCT program implementation by national health-professional associations

(pediatrics, obstetrics/gynecology, and midwifery), the MOH HIV care and reproductive-health programs,

and district health teams to improve ownership, training, and supervision of integrated PMTCT services by

key stakeholders.

Despite these successes, EGPAF is not satisfied with the performance of the PMTCT program in Côte

d'Ivoire. Gains, especially regarding coverage, remain slow, and despite two years of technical assistance

to improve integration with antenatal care at all sites, PMTCT programs have resisted change, continuing to

support standards inherited from a time when PMTCT in Côte d'Ivoire was conducted as part of research

trials testing the efficacy of various ARV prophylaxis interventions.

In response to lower-than-anticipated results, EGPAF will significantly shift approaches over the remainder

of the FY07 program year. In FY08, EGPAF intends to expand to 132 sites providing HIV testing for

120,000 women and ARV prophylaxis for 8,400 women. A majority of new sites will be in the North, in areas

previously under nongovernment Forces Nouvelles control. This will require significantly more travel and will

have a series of increased costs (logistics, supply chain, renovations, etc.) but is necessary to bring some

parity to HIV/AIDS services in the various regions of the country. This aggressive expansion will be based

on a series of new intervention principles centered on a more "public health" approach to PMTCT

expansion, including:

• Improved integration of PMTCT in existing ANC programs

o The inclusion of the National Reproductive Health Program (PNSR) as well as the National HIV/AIDS

Care and Treatment Program (PNPEC) in the development of the program

o The diffusion of joint directives from both programs to lead PMTCT programming

o Including PMTCT in the definition of the "minimum package" of ANC activities

• Extensive health-promotion activities to increase PMTCT uptake within ANC and maternity programs

• Expansion of the district approach that has proved successful in Abengourou

• Development of regional training teams to support district-led implementation

• Increased reliance on partnerships with NGOs, faith-based organizations, and the private sector to

promote community linkages with other maternal child health and HIV/AIDS programs, such as OVC

programs.

• Nearly universal opt-out testing

• Rapid expansion of rapid-test, finger-prick HIV diagnostics to replace the venous blood draws/spun

plasma currently required for HIV testing.

The successful interventions described at the beginning of this section will be retained through planned

scale-up and expansion of services. Through the district approach, EGPAF will cover at least 50% of the

health facilities in each health district. The district health team will take the lead in site assessments, activity

implementation, and supervision. EGPAF will provide technical assistance and logistical support.

At all PMTCT, ART, and CT sites, EGPAF will provide - either through direct hire or by contracting with

individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for PLWHA and their children. EGPAF will

engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for BCC interventions

focusing on ABC methods of risk reduction, as well as partner testing and STI prevention and care. HIV-

positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will include

ABC prevention interventions (including disclosure, partner and family testing, and STI prevention and care)

and referral to community-based OVC and palliative care services to address family and individual care

needs. Where possible, family-planning services will be provided through wraparound programming by non-

PEPFAR funded partners, and condoms will be provided free of charge.

All HIV-positive clients will be offered information about and referrals to specific community-based OVC

care and palliative care services tailored to their needs. EGPAF will ensure that community-based services

capable of meeting these needs are identified, and EGPAF will be responsible for monitoring and reporting

Activity Narrative: on referrals according to a nationally standardized referral system.

EGPAF will continue to work with the MOH, UNICEF, UNFPA, JHPIEGO, ICAP-Columbia University,

ACONDA, and other partners to refine overall national policies, guidelines, and plans for scaling up PMTCT

and associated services in strategic geographic areas while emphasizing some of the newer approaches,

particularly finger-prick diagnostics and opt-out testing. Quality-assurance programs for PMTCT activities

will be coordinated closely with PEPFAR-funded partner URC. EGPAF will also continue to coordinate with

SCMS and the USG for procurement of all HIV-related commodities to avoid stock-outs. Regarding

laboratory services, EGAPF will rely on CDC/Projet RETRO-CI, the national network of laboratories, CDC

Lab Coalition partners, and other relevant national or international reference labs for support of PMTCT

services and quality control.

EGPAF will continue to work with community-based partners such as Alliance CI, ANADER, and CARE

International to improve linkages with community mobilization and psychosocial support through community

workers and PLWHA. NGOs and CBOs will be identified in each health district in collaboration with RIP+

(network of PLWHA organizations) to perform community-based activities around PMTCT sites. EGPAF will

collaborate with FHI for linkages with social services and OVC programs; Measure/JSI for M&E; and PATH,

Helen Keller International Foundation, and the World Food Program for nutritional support.

EGPAF will continue providing support to UNFPA programs to solidify the linkages between reproductive-

health services and PMTCT. Technical support from JHU/CCP will continue for the development or

adaptation of job aids, client information, and other materials. EGPAF's continuum-of-care approach for

bridging PMTCT and ART activities is described in the accompanying ART narrative but applies equally to

PMTCT (refer to activity #10068) and will be applied at all PMTCT sites. EGPAF will collaborate with the

MOH and the USG team in PHE activities.

EGPAF's M&E team 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, EGPAF will participate in quarterly SI

meetings and will implement decisions taken during these meetings.

Noted April 16, 2008:

EGPAF will also provide subgrant funding and technical assistance to several subpartners formerly

supported through Alliance National Contre le SIDA.

Facility-based health services represent a critical opportunity to impact client behavior through clear,

authoritative health messages delivered in one-on-one or small-group settings, as well as to connect clients

effectively with community-based care services. To use the opportunity to reduce risk behavior and thus

HIV transmission, all PEPFAR Cote d'Ivoire ART and PMTCT service providers will ensure that their

package of services includes HIV prevention behavior-change communication promoting risk reduction

through abstinence, fidelity, correct and consistent condom use, status disclosure, partner testing, and STI

prevention and care targeting both HIV-positive and HIV-negative clients. In addition, they will ensure that

all HIV-positive clients are offered effective, monitored referrals to community-based OVC and palliative-

care services.

HIV-negative clients at PMTCT and CT sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a community counselor for

behavior change communication interventions, delivered individually or in small groups, focusing on risk

reduction through abstinence and fidelity, with correct and consistent condom use for those engaged in high

-risk behavior, as well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT and ART sites:

Addressing prevention with HIV-positive patients is an important part of a comprehensive prevention

strategy. Through healthy living and reduction of risk behaviors, these prevention interventions can

substantially improve quality of life and reduce rates of HIV transmission. The goal of these interventions is

to prevent the spread of HIV to partners and infants born to HIV-infected mothers and protect the health of

infected individuals.

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a community

counselor for individual counseling that will include HIV prevention interventions and referral to community-

based OVC and palliative care services. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Family-planning counseling and services will be provided to patients and their

partners through wraparound programming by other non- PEPFAR funded partners. Condoms will be

provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. EGPAF will ensure that

community-based services capable of meeting these needs are identified and will be responsible for

monitoring and reporting on referrals.

EGPAF will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services.

This entry represents the Abstinence and Being Faithful portion of the comprehensive prevention package.

This programmatic area is addressed in several components of the intervention. Counselors will be trained

to assess and address sexual risk behavior and to deliver tailored AB messages using culturally appropriate

visual aids. In each of these interventions, patients are encouraged to remain abstinent to protect their own

health and avoid transmission to partners. Patients who are sexually active are also encouraged to remain

faithful to one partner. Abstinence is also promoted in the family planning and STI trainings as a method of

preventing pregnancy and STI transmission.

EGPAF 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, EGPAF will participate in

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

Facility-based health services represent a critical opportunity to impact client behavior through clear,

authoritative health messages delivered in one-on-one or small-group settings, as well as to connect clients

effectively with community-based care services. To use the opportunity to reduce risk behavior and thus

HIV transmission, all PEPFAR Cote d'Ivoire ART and PMTCT service providers will ensure that their

package of services includes HIV prevention behavior-change communication promoting risk reduction

through abstinence, fidelity, correct and consistent condom use, status disclosure, partner testing, and STI

prevention and care targeting both HIV-positive and HIV-negative clients. In addition, they will ensure that

all HIV-positive clients are offered effective, monitored referrals to community-based OVC and palliative-

care services.

HIV-negative clients at PMTCT and CT sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a community counselor for

behavior change communication interventions, delivered individually or in small groups, focusing on risk

reduction through abstinence and fidelity, with correct and consistent condom use for those engaged in high

-risk behavior, as well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT and ART sites:

Addressing prevention with HIV-positive patients is an important part of a comprehensive prevention

strategy. Through healthy living and reduction of risk behaviors, these prevention interventions can

substantially improve quality of life and reduce rates of HIV transmission. The goal of these interventions is

to prevent the spread of HIV to partners and infants born to HIV-infected mothers and protect the health of

infected individuals.

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a community

counselor for individual counseling that will include HIV prevention interventions and referral to community-

based OVC and palliative care services. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Family-planning counseling and services will be provided to patients and their

partners through wraparound programming by other non- PEPFAR funded partners. Condoms will be

provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. EGPAF will ensure that

community-based services capable of meeting these needs are identified and will be responsible for

monitoring and reporting on referrals.

EGPAF will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services.

This entry represents the Other Prevention portion of the comprehensive prevention package. This

programmatic area is addressed in several components of the intervention. Counselors will be trained to

assess and address sexual risk behavior and to deliver tailored OP messages using culturally appropriate

visual aids. In each of these interventions, patients are encouraged to remain abstinent to protect their own

health and avoid transmission to partners. Patients who are sexually active are also encouraged to remain

faithful to one partner. Furthermore, the prevention approach, "positive prevention," aims to protect the

health of HIV-infected individuals and prevent the spread of HIV to sex partners and infants. Because an

HIV-positive person is involved in the transmission of each new infection, prevention interventions aimed at

people infected with HIV can have a larger effect on disease spread than comparable efforts aimed at

people who are not infected. This makes positive prevention an essential part of a comprehensive

prevention approach. Key prevention steps at each clinic visit will be the delivery of behavioral prevention

messages (including addressing issues relevant to discordant couples), STI management, discussing family

planning needs, and assessment for heavy alcohol use and ARV adherence.

EGPAF 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, EGPAF will participate in

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

Noted April 16, 2008:

This funding represents a percentage of Alliance CI 's palliative care funds reprogrammed to EGPAF to

provide financial, programmatic, technical and overall capacity building support to subpartners who received

grants in FY 07 to continue providing uninterrupted palliative care services in the zones EGPAF is working.

EGPAF will also provide subgrant and technical assistance to several subpartners formerly supported

through Alliance National Contre le SIDA.

Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has received USG funds through

Project HEART to provide comprehensive, family-centered HIV/AIDS care and treatment services. By

March 2009, EGPAF expects to be supporting 100 sites providing ART for 35,000 patients.

The benefits of keeping close track of HIV-positive patients with high CD4 counts are significant, as early

initiation of ART has been demonstrated to greatly improve treatment outcomes. For FY08, EGPAF

proposes that the bulk of the funding for palliative care be used to support HIV+ patients enrolled in care but

not yet eligible for ART. These patients will be scheduled for quarterly check-ups, receive CD4 tests twice a

year, and be encouraged to come in for all significant illness episodes free of charge. They will receive

routine cotrimoxazole prophylaxis and nutrition assessment and counseling, which have been shown to

delay the need for treatment initiation. All TB/HIV co-infected patients and all pregnant women not yet

eligible for ART from PMTCT will receive the same package. At least 10% of enrolled patients will be

children, who will receive pediatric formulations of cotrimoxazole (either with Clinton Foundation support or

through SCMS). Well-functioning referrals and counter-referrals will be established with PEPFAR-funded

OVC partners for testing and care.

While advocating and working for a consensus on a standardized affordable package of care to be available

across the health system, EGPAF has actively participated in efforts led by the MOH palliative care task

force to develop a national palliative-care policy along with a list of essential OI drugs adapted to different

health-care and community settings and a set of training curricula.

The current standard of cotrimoxazole and nutritional support will be supplemented by an aggressive

attempt to bring in more donated fluconazole (working with BI and MAP International) to reach underserved

populations in the interior of the country (starting in Bouaké, with progressive expansion to other regional

hospitals). The current fluconazole donation program through Pfizer is limited to large hospitals in Abidjan.

To date, the specific basic-care package that most of EGPAF's implementing partners are providing

includes free OI prophylaxis with cotrimoxazole, fluconazole (where available), food assessment and

support through a partnership with HKI, condoms provided by USAID, and oral rehydratation salts.

Provision of Vitamin A is systematic twice a year for infants between 6 and 59 months and for women

postpartum as part of the national policy supported by UNICEF. It is expected that the program will receive

safe-water products and impregnated bed nets through SCMS, to be distributed to targeted high-risk groups

(young children, pregnant women, areas with poor water quality, etc.). At heavily subsidized prices, EGPAF

partners will also provide care for infections such as malaria, toxoplasmosis, and septicemias.

As part of its wraparound activities, EGPAF (assisted by PATH) has signed a memorandum of

understanding with the World Food Program to provide food supplementation to HIV-positive malnourished

pregnant women and their exposed children. Due to WFP's stringent criteria, fewer than 400 people (June

2007) have been receiving food supplementation at four pilot sites in Abengourou, San Pedro, and Abidjan.

Two EGPAF sub-grantees in Yamoussoukro and Bouake benefit directly from WFP food aid and have

instituted cooking workshops integrating local high-calorie and high-protein products into the diets of HIV-

positive patients.

Other palliative-care activities to be supported with FY08 funding include:

• Reinforce partnership with RIP+ (network of PLWHA organizations) to empower nascent PLWHA support

groups in the interior of the country, progressively expanding to at least one-third of EGPAF-supported sites

• Contract with ASAPSU or a partner TBD to reinforce and expand food distribution as part of wraparound

activities

• Develop a positive-prevention package for clinical settings that also addresses family planning, disclosure,

and speaking to adolescents about their HIV status and lifelong treatment. Existing English tools and

curricula will be translated into French, adapted, and implemented gradually in close collaboration with

PEPFAR partners.

• Reinforce the partnership with Helen Keller International to couple food supplementation to income-

generating activities with WFP support. Greater involvement of PATH in the training of community support

groups or caregivers will complement this activity.

• Continue to assist in the development and dissemination of palliative-care guidelines, job aids, brochures,

and a training curriculum (in partnership with FHI and Alliance CI) and train 200 care providers (physicians,

nurses, social workers, and community caregivers) in a complete palliative-care package.

• Document the impact of palliative-care services by tracking patient morbidity/mortality as well as

adherence to care and treatment. This information will inform the national policy as part of the program

evaluation, with technical assistance from JSI/Boston.

EGPAF's work complements the efforts of Alliance CI, CARE International, and FHI, which have community

capacity-building and empowerment activities in the same implementation areas. As agreed through an

MOU, Alliance-funded home-based care projects will link with EGPAF clinical sites to provide home-based

support to patients with advanced illness. EGPAF will also continue to work closely with the national HIV,

TB, and Reproductive Health programs, as well as other PEPFAR partners (CARE, PSI, ACONDA, and

ANADER), which have referral systems that usher patients into EGPAF's comprehensive care program.

At all sites, EGPAF will provide - either through direct hire or by contracting with individuals or local

organizations - counselors dedicated to providing a comprehensive package of HIV prevention

interventions for all clients and effective referrals for persons living with HIV/AIDS and their children. EGPAF

will engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients. A rule

of thumb is that per day, one counselor might provide HIV prevention interventions in small-group sessions

for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral services in

individual sessions for up to 10 HIV-positive clients.

Activity Narrative:

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will

include HIV prevention interventions and referral to community-based OVC and palliative care services to

address family and individual care needs. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Where possible, family-planning counseling and services will be provided to

patients and their partners through wraparound programming by other non-PEPFAR funded partners, and

condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their needs. With assistance from the National OVC

Care Program (PNOEV) and the PEPFAR in-country team, EGPAF will ensure that community-based

services capable of meeting these needs are identified, and EGPAF will be responsible for monitoring and

reporting on referrals according to a nationally standardized referral system.

EGPAF will work closely with SCMS to forecast and develop a procurement plan that will ensure

uninterrupted supplies of commodities.

EGPAF will work to improve sustainability by involving the national HIV and TB programs and district health

teams in joint planning, staff training, and establishment of efficient commodities management and M&E

systems. In collaboration with other PEPFAR partners, EGPAF will support advocacy and sensitization

campaigns targeting decision-makers, community leaders, health professionals, CBOs, and FBOs to

mobilize more resources for HIV/AIDS.

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

program data. To participate in the building and strengthening of a unified national M&E system, EGPAF will

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

Noted April 21, 2008: EGPAF will also prvide subgrant funding and technical assistance to several

subpartners formerly supported through Alliance National Contre le SIDA.

Since 2005, the USG has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the

Ministry of Health in supporting and expanding quality TB/HIV care in Cote d'Ivoire while building on and

complementing other programs supported by the EP, Global Fund, UNICEF, and others. The USG has

supported EGPAF in developing a holistic, family-centered approach to HIV prevention, care, and treatment

within the health sector.

Integration of TB and HIV services is an overarching goal for Project HEART and the whole EP program.

Integration is being achieved through the provision of routine HIV counseling and testing (CT) services at

TB diagnostic sites, provision of TB and HIV care for co-infected patients at TB treatment sites, and TB

screening and referral at all HIV service sites.

To date, EGPAF has assisted the Ministry of Health (MOH) to provide free routine HIV testing (moving from

an "opt-in" to provider-initiated routine CT) in six specialized TB centers with a case load of more than

10,000 patients a year out of the annual country-wide case load of 21,000 active TB patients. These

activities have resulted in greatly improved HIV testing uptake among TB patients and the identification of

HIV-infected TB clients in need of joint HIV and TB care.

Activities include increasing clinical capacity to provide routine provider-initiated CT services, implementing

a functional referral system (linking clinics providing HIV and/or TB diagnosis with those providing HIV and

TB care and treatment services), enhancing community-level support to promote adherence and successful

treatment outcomes, and care for families of HIV- and TB-affected persons through screening for TB and

HIV in the household. PEPFAR funds are used to train health-care providers, perform minor facilities

renovation if needed, and provide ARVs through a coordinated procurement process at the national level.

EGPAF initiated an advocacy dialogue with the national TB control program to effectively and quickly

implement aggressive routine, provider-initiated CT. This is being supported by technical assistance from

both the CDC and ISPED/University of Bordeaux. An ongoing demonstration phase has started at the CAT

d'Adjame and the PPH ward of the University Hospital of Cocody, with changes to patient flow and the

systematic offering of HIV testing and early results to all patients attending the clinic. This new strategy has

shown a dramatic increase in the number of patients tested and treated for TB/HIV at the two centers. At

CAT d'Adjame the rate of HIV testing has moved from 34% to 80% and the average monthly rate of new

patients enrolled into care from 57 to 120. The figures at CHU Cocody are quite similar with an HIV testing

rate moving from 55% to 99 % and the monthly average rate of new patients enrolled from 32 to 59.

Preliminary analysis of the results at CHU Cocody has surprisingly revealed a higher HIV prevalence rate

among non-TB related hospitalized patients. This demonstrates that the systematic offer of HIV testing in

TB centers results in the detection of HIV-infected patients without TB.

Based upon these results, EGPAF in collaboration with the national TB control program and leading TB

care providers have been taking the leadership to change national policy and are designing new training

curriculum and materials to support a rapid scale-up of this new strategy across the country.

Simultaneously quality assessment and quality improvement activities undertaken at CAT d'Adjame have

helped to identify weaknesses that are being addressed to improve the quality of services. Findings of these

assessments have helped to improve the training curriculum and the implementation of the new strategy at

the new sites.

• As results of previous and current efforts EGPAF will surpass its PY 4 targets of initiating HIV treatment for

5,180 TB/HIV co-infected patients, at current trends EGPAF should reach close to 7,100 HIV/TB co-infected

patients this year.The plus-up funding awarded to EGPAF in July 2007 will help equip all 8 TB centers with

fluorescence microscope to improve TB diagnosis to meet the national standards and provide financial and

logistic support to CATs to expand TB/HIV programs to CDTs under their responsibility; support will include

but is not limited to: training materials, binocular microscopes, tools and resources for supervision, lab

supplies, registers for data collection, initial and refresher trainings, etc.

In support of the national priorities of the TB and HIV programs and in collaboration with the EP and other

partners, EGPAF will use FY08 funds to:

• Strengthen activities undertaken during PY 07 at the current 44 EGPAF-supported TB sites (8 CATs and

36 CDTs) and 57 ART sites

• Expand support for TB/HIV activities to 18 additional CDTs

• Continue to provide a comprehensive package of services to the existing 101 (44 Tb clinics + 57 HIV sites)

TB/HIV sites and the 8,400 new TB/HIV patients to be enrolled into HAART by the end of March 2009

• Collaborate with PNLT will roll out the provider initiated counseling and testing approach at all the TB

clinics. EGPAF will strive to test 100% TB patients (16,800) diagnosed at the supported sites. All the co-

infected patients will be given cotrimoxazole prophylaxis.

• Revise patient flow pattern used at CAT Adjame and Cocody to systematically offer HIV testing earlier

and provide the results on the same day will be adopted at all the CAT and CDTs supported by EGPAF.

• Systematically screen all patients attending HIV care and treatment sites at registration and each follow up

visit using the TB screening tool developed by PNLT. INH prophylaxis will be given to eligible patients

according to national guidelines.

• Implement the newly adopted simplified HIV testing algorithm using finger prick test and/or oral testing to

increase the uptake of HIV testing at the main 8 regional TB centers and CDTs supported by EGPAF

• Continue working in close collaboration with the TB control program recipient of the Global Fund TB grant,

and the lung disease specialists health professional association to improve TB/HIV diagnosis (including

children) as part of a family-centered approach, with follow-up of family members of the HIV/TB co-infected

clients

• Expand TB screening, diagnosis, and treatment in HIV-infected patients at "HIV" points of entry (CT,

PMTCT, etc).

• Improve and expand quality assessment and improvement activities in the 8 regional TB centers to

improve the overall quality of services provided to TB/HIV co-infected patients and their families

• Conduct training for all categories of staff working at TB/HIV care centers (medical doctors, nurses, social

workers and community care givers) using the new training curriculum and tools

Activity Narrative: • Provide additional trained staff at the TB centers in the Central, and Northern regions of the country where

there are severe human resource shortages while working with the Ministry of Health, donors and UN

agencies involved in the fight against HIV/AIDS to hasten the redeployment of government health workers

in these regions

• Support to organize information and coordination meetings at the district and regional levels as well as

facilitate exchange visits between TB and HIV treatment centers

• Provide resources to regional TB centers and districts to strengthen their data management capacity and

also enable them to perform regular formative supervision activities

• In collaboration with PNTL and ASM, support decentralization of rapid TB liquid culture to 3-4 regional TB

clinics in the central, northern and western regions of the country.

• Infection control measures including administrative controls and renovations as required will be done at all

the CATs.

• Support TB culture for all cases of treatment failure as well as for diagnosis of smear negative cases.

In addition an emphasis will be put on:

• Wraparound activities involving TB and HIV NGOs, CBOs, and FBOs dealing with TB and HIV to deepen

and update their understanding and knowledge of TB-HIV co-infection related issues, in partnership with

other EP partners and in particular with Alliance Cote d'Ivoire linked to EGPAF by a MOU signed in June

2007. With the support of PAM, EGPAF will also extend its food aid program to malnourished TB/HIV co-

infected patients including children

• Joint planning and coordination to increase system-strengthening efforts in M&E (JSI); laboratory

(APHL/RETRO-CI); commodities management (SCMS); and human capacity, training, and performance

standards (Abt Associates/JHPIEGO/CCP). Ongoing technical assistance will be sought from the USG,

WHO, and other experts. Availability of TB commodities will be assured by the national TB program with

support from the Global Drug Facility.

• Building sustainability through the empowerment of both government institutions (HIV, TB programs) and

community organizations dealing with TB/HIV co-infection: joint planning, trainings, sensitization campaigns,

and reinforcement of M&E capacity. EGPAF will provide medical, IT, and logistic equipment as needed.

Noted April 17, 2008: EGPAF will also provide subgrant funding and technical assistance to several

subpartners formerly supported through Alliance National Contre le SIDA.

Since 2004, PEPFAR has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the

Ministry of Health in supporting and expanding quality ART, PMTCT, and palliative care services in Cote

d'Ivoire while building on and complementing other programs supported by PEPFAR, the Global Fund,

UNICEF, and others. PEPFAR has supported EGPAF in developing a holistic, family-centered approach to

HIV prevention, care, and treatment within the health sector.

In addition to providing medical care and treatment, facility-based health services represent a critical

opportunity to impact client behavior through clear, authoritative health messages delivered in one-on-one

or small-group settings, as well as to connect clients effectively with community-based care services. To

use the opportunity to reduce risk behavior and thus HIV transmission, all PEPFAR Cote d'Ivoire ART and

PMTCT service providers will ensure that their package of services includes HIV prevention behavior-

change communication promoting risk reduction through abstinence, fidelity, correct and consistent condom

use, status disclosure, partner testing, and STI prevention and care targeting both HIV-positive and HIV-

negative clients. In addition, they will ensure that all HIV-positive clients are offered effective, monitored

referrals to community-based OVC and palliative-care services.

At all its PMTCT and ART sites, EGPAF will provide - through direct hire or, more commonly, by contracting

with individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for persons living with HIV/AIDS and their

children.

EGPAF will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

HIV-negative clients at PMTCT, CT, and TB sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT, ART, TB, and CT sites:

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a counselor for

individual counseling that will include HIV prevention interventions and referral to community-based OVC

and palliative care services to address family and individual care needs now and in the future. Targeted HIV

prevention counseling will focus on risk reduction through abstinence, fidelity, correct and consistent

condom use, disclosure, testing of partners and children, and STI prevention and care. Where possible,

family-planning counseling and services will be provided to patients and their partners through wraparound

programming by other non- PEPFAR funded partners, and condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. In these individual sessions,

the counselor will seek to obtain contact information (e.g. address, telephone number) for the client and

briefly assess the client's needs and resources. The counselor will provide the client with a brochure or

other illustrated materials showing what the palliative care and OVC care services might include, such as

clean water and bed nets for palliative care and educational, medical, nutritional, legal, and psychosocial

support for OVC. The counselor will then ask the client whether she or he would like to provide the names

of people in the household who might need referral to such services.

With assistance from the National OVC Care Program (PNOEV) and the PEPFAR in-country team, EGPAF

will ensure that community-based services capable of meeting these needs are identified, and EGPAF will

be responsible for monitoring and reporting on referrals according to a nationally standardized referral

system.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services for persons living with HIV. The program's effort will

reflect the funding and proportions noted here.

Since 2004, PEPFAR has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) in developing

and implementing a holistic, family-centered approach to HIV prevention, care, and treatment within Cote

d'Ivoire's health sector, including quality counseling and testing (CT) services. Since 2006, the main

component of EGPAF's CT program has been to integrate routine, provider-initiated HIV testing into clinical

settings where EGPAF supports care and treatment. The idea has been to extend CT services beyond

patients in the infectious-disease service or arriving specifically to be tested to cover all inpatients and a

substantial portion of outpatients at any EGPAF-supported site. Particular emphasis was placed on the

integration of routine, provider-initiated CT in the two large teaching hospitals of Abidjan in order to be able

to document and develop the tools necessary to go to scale in hospitals around the country.

In the first three months of 2007, 16,716 people (excluding PMTCT clients) were counseled and tested in

sites supported by EGPAF. At the CHU/Treichville alone, 2,846 people were tested in the five services that

have adopted this approach, and 981 of these have been put on ART. These patients supplement the

steady growth of ART patients in the Infectious Disease Unit (SMIT), the main center for ART at CHU-

Treichville. As this initiative is only just starting, it is imagined that the number of patients tested at the CHU-

Treichville will continue to increase this year, and the program should test approximately 40% of the

estimated 30,000 hospitalized patients in Treichville by the end of 2007.

The CHU-Cocody has responded more slowly to the initiative; as of August 2007; only the pulmonary

service, with support from EGPAF's TB/HIV team, had aggressively pursued CT of all patients.

Both institutions will be encouraged to work more aggressively to counsel and test their outpatients. They

have about 125,000 outpatient consultations a year combined; assuming a typical patient has two visits per

year, this represents a pool of 62,500 potential CT clients per year. Since ambulatory cases present with

fewer disease symptoms than hospitalized cases, it has been more difficult to convince overworked staff to

counsel and test outpatients. Advancing on this front is of the highest priority for the funds being requested

for FY08.

Results might have been even more impressive if not for frequent stock-outs in test kits over the past year.

Even when the Public Health Pharmacy (PSP) was able to deliver test kits, it has frequently delivered fewer

than requested, causing all EGPAF sites to offer testing to fewer patients than they would have otherwise.

In addition, these stock-outs have a tendency to de-motivate the hospital staff to pursue HIV testing.

EGPAF has partnered with the local NGO GROFORMED to extend the model developed at CHU-Treichville

and CHU-Cocody to four regional hospital complexes in the interior of the country. The expected adoption

of a simplified finger-prick, whole-blood testing algorithm for HIV infection should enable EGPAF to expand

into rural zones that do not have linkages to laboratories. Combined with necessary policy changes and

training and supervision, the simplified algorithm will enable nurses and midwives to provide CT services, a

requirement for the program to be successful outside larger cities.

Another NGO, Renaissance Sante Bouake, with EGPAF technical and financial support has started a

demonstration home-based CT intervention in four villages around Yamoussoukro, with planned expansion

to four more villages at the end of March 2009. EGPAF is in the process of documenting this and other CT

approaches it has implemented in Côte d'Ivoire over the past few years, including:

• The EGPAF continuum-of-care strategy implemented at PMTCT sites in Abengourou, Agnibilekro, and

Grand Bereby

• Family-based models piloted in Bouaké

• Extension of CT through family-planning sites

• Routine CT at TB centers, with greatly increased uptake

EGPAF is working closely with the CT working group at the National HIV/AIDS Care and Treatment

Program (PNPEC) to document practices that will enable PNPEC and its partners to go to scale with proven

strategies.

With FY08 funding, EGPAF's priorities will include the following CT intervention strategies:

• Reinforcement of CT for hospitalized patients and a push to greatly increase testing of ambulatory patients

in the large Abidjan hospitals supported by EGPAF

• Integration of CT in 80% of the regional hospitals and of districts in the intervention zones of EGPAF's

Project HEART

• Continued expansion of routine CT for all TB patients in TB treatment centers and progressive

decentralization of this activity out toward health facilities with TB "corners"

• Greatly expanded numbers of infants tested using PCR (initially through the transport of whole blood, then

moving toward a DBS strategy for sites farther from PCR laboratories). Children testing HIV-positive will be

offered access to treatment as part of the family approach and linked to on- or off-site OVC services

• Expanded reliance on the simplified rapid-test algorithm at all sites supported by EGPAF

• Expanded home-based CT strategies around five well-performing HIV care sites

• Improved linkages of care and treatment activities, including TB/HIV, PMTCT, and STI clinics, to access to

ART eligibility screening for all HIV-positive patients and to comprehensive palliative care for those not

eligible for ART, with referral to OVC services for their children

• Improved M&E systems that will enable EGPAF to identify clients who have not been picked up through

ongoing care and treatment and PMTCT programs (i.e. a system that allows tracking of which clients are

being picked up by specific CT approaches).

"Prevention for positives" interventions will be conducted in partnership with RIP+ (national network of

PLWHA organizations) and technical assistance from PEPFAR's special Prevention with Positives initiative

at CHU-Treichville and at least three faith-based or community health centers. An aggressive community

awareness campaign promoting CT will be undertaken using media, community leaders, peer educators,

and local drama groups, in close collaboration with JHU-CCP, REPMASCI (network of journalists and

artists), and Alliance-CI.

Partner and couples testing will be a high priority, building on a stronger family-centered approach in

Bouake, Yamoussoukro, Ouangolo, Ferke, Dimbokro, and Sainte Thérèse Enfant Jesus in Abidjan.

FY08 activities will provide CT services to at least 50,000 people, a majority through testing non-HIV

admissions and outpatients of hospitals and the rest through family-based and continuum-of-care

Activity Narrative: approaches at EGPAF-supported sites.

At all sites, EGPAF will provide - either through direct hire or by contracting with individuals or local

organizations - counselors dedicated to providing a comprehensive package of HIV prevention

interventions for all clients and effective referrals for persons living with HIV/AIDS and their children. EGPAF

will engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will

include HIV prevention interventions and referral to community-based OVC and palliative care services to

address family and individual care needs. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Where possible, family-planning counseling and services will be provided to

patients and their partners through wraparound programming by other non-PEPFAR funded partners, and

condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their needs. With assistance from the National OVC

Care Program (PNOEV) and the PEPFAR in-country team, EGPAF will ensure that community-based

services capable of meeting these needs are identified, and EGPAF will be responsible for monitoring and

reporting on referrals according to a nationally standardized referral system.

EGPAF will continue to improve an M&E system tracking project-specific, PEPFAR, and national indicators.

EGPAF 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, EGPAF will participate in quarterly SI meetings

and will implement decisions taken during these meetings.

Noted April 21, 2008: EGPAF will also provide subgrant funding and technical assistance to several

subpartners formerly supported through Alliance national Contre le SIDA.

Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has received USG funds through

Project HEART to provide comprehensive care and treatment services to more than 88,00 PLWHA,

including 40,000 on ART at 77 sites.

In June 2007, 18 sites managed by EGPAF sub-grantee ISPED/ACONDA (and accounting for about 14,000

patients on ART) moved from Project HEART when ACONDA graduated to become a PEPFAR prime

partner. Thus, EGPAF now supports 59 sites with 26,000 patients who have initiated ART. With FY07

funds, EGPAF aims to support 75 sites (including 16 new sites) with 33,000 patients ever receiving ART

and 29,700 patients actively receiving ART.

EGPAF works to implement a family-centered approach to delivering care and treatment. Currently, 6% of

the patient load is pediatric cases, and EGPAF is working assiduously to raise this above 10%. Key

strategies in the past year include:

• Implementation of a formal continuum-of-care "network model" to link women identified as HIV-positive in

PMTCT programs to ART programs and to enroll their HIV-exposed children in care and treatment

programs

• Using a performance-based contracting (PBC) model that reimburses partners based on a series of results

rather than on a cost-reimbursable basis

• Expansion of the "district model" approach, working in close collaboration with health structures and

systems to share more responsibility with MOH staff in site selection, needs assessment, and supervision

• Expansion of DNA PCR-based infant diagnostics to enroll more children at an early age into care and

treatment programs. This strategy was complemented by identification and capacity-building at four

hospitals in provision of pediatric ART

• Adaptation of tools and approaches to support infant feeding based on WHO recommendations, in

partnership with PATH and HKI/Abidjan; and introduction of the WHO-approved infant-feeding training

curriculum for HIV-exposed children targeting doctors, nurses, and social workers

• Expansion of program quality assurance to more than 25% of supported sites with the goal of reaching

more than 50% by the end of FY07

• Expansion of public-private partnerships to support more Ivorian businesses with their own health systems

or clinics in HIV prevention, care, and treatment.

All these strategies follow national guidelines enabling replication beyond EGPAF-supported sites and

sustainability. EGPAF works closely with the National HIV/AIDS Care and Treatment Program (PNPEC).

In both performance-based and cost-reimbursable formats, direct support to sites is provided in accordance

with national standards in terms of commodities, equipment, trained staff, laboratory services, and M&E.

Implementation is coordinated with PNPEC and may be direct (public sites) or through implementing sub-

partners. EGPAF seeks to ensure continuum-of-care services and service promotion at the community and

home levels (through partnerships with the network of PLWHA organizations, Alliance CI, CARE

International, ANADER, and other partners).

EGPAF works with SCMS and the Public Health Pharmacy (PSP) to support quantification and provide ARV

drugs and commodities at supported sites. Laboratory services are coordinated with the Ministry of Health,

APHL, CDC/Projet RETRO-CI, and the national network of laboratories.

FY08 funds will permit EGPAF to provide ongoing support to the 75 existing sites and 29,700 patients

expected to be on active ART by March 2008 as well as to provide services to 25 additional sites, with

35,000 patients on active ART at 100 supported sites by March 2009. In an attempt to balance ART service

provision, a majority of new sites will be in the northern and western parts of the country previously under

the control of nongovernment military forces.

While activities described above will provide the framework for care and treatment, several new initiatives

will be promoted to further strengthen the program. These include:

• Open EGPAF's first Côte d'Ivoire sub-office in Bouaké. This office will enable EGPAF to expand services

much more quickly in Bouaké and surrounding areas by providing timely support to sites and districts.

EGPAF will also consider opening sub-offices in Abengourou and elsewhere;

• Collaborate with Alliance and JHU/CCP to intensify HIV services promotion in the community and to

strengthen the capacities of community-based organizations;

• In addition to evaluating HIV-exposed infants through DNA PCR using dried blood spot sample collection

whenever possible, EGPAF will support implementation of the WHO-approved IMCI HIV diagnostic tool in

tandem with antibody testing to increase the number of infants put on early treatment. This approach will be

used in rural areas where PCR testing is unavailable. EGPAF will ensure that at least 10% of HIV care and

treatment patients enrolled at the 100 sites are infants and children (3,500 patients on ART);

• Support a pediatric treatment communication campaign at the national level in collaboration with the MTN

Foundation (affiliated with the MTN cellular-telephone company) to increase awareness of pediatric

HIV/AIDS services;

• Further refine the performance-based contracting model and shift some partners currently supported

through cost-reimbursable grants to PBC;

• Expand infant-feeding tools and approaches to all EGPAF-supported sites;

• Expand the EGPAF quality assurance system to all supported sites;

• Introduce an EGPAF-wide M&E database to conduct true cohort analyses and generate data for

comparison between all 19 EGPAF country programs;

• In collaboration with local NGOs and CBOs directly supported by EGPAF, EGPAF will work more closely

with social workers and community counselors (including PLWHA) to improve adherence to treatment,

reduce loss to follow-up, and provide psychosocial support, OVC care, and prevention for positives

interventions.

In a further attempt to institutionalize and make sustainable the activities supported by EGPAF with

PEPFAR funding, EGPAF's recent partnerships with and support of National Medical and Social Worker

training institutions will be expanded to increase the human resources available to Côte d'Ivoire to fight the

HIV epidemic, prevent new infections, and treat people already infected with the virus.

In addition to the technical assistance received from CDC/Retro-CI for quality assurance for HIV testing,

Activity Narrative: EGPAF will seek technical assistance locally and in the Africa region to address urgent issues related to QA

for biochemistry and hematology exams, including development of standard operating procedures and good

clinical laboratory practices.

At all ART, PMTCT, and CT sites, EGPAF will provide - either through direct hire or by contracting with

individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for PLWHA and their children. EGPAF will

engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for BCC interventions

focusing on ABC methods of risk reduction, as well as partner testing and STI prevention and care. HIV-

positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will include

ABC prevention interventions (including disclosure, partner and family testing, and STI prevention and care)

and referral to community-based OVC and palliative care services to address family and individual care

needs. Where possible, family-planning services will be provided through wraparound programming by non-

PEPFAR funded partners, and condoms will be provided free of charge.

All HIV-positive clients will be offered information about and referrals to specific community-based OVC

care and palliative care services tailored to their needs. EGPAF will ensure that community-based services

capable of meeting these needs are identified, and ACONDA will be responsible for monitoring and

reporting on referrals according to a nationally standardized.

Since 2004, the USG has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the

Ministry of Health (MOH) in supporting and expanding HIV/AIDS care and treatment and PMTCT programs

while building on and complementing other programs supported by PEPFAR, the Global Fund, UNICEF,

and others. EGPAF supports program implementation through a variety of sub-recipients

(NGO/CBO/FBO/private-sector partners) to provide HIV services in the health sector. To support and

motivate these sub-partners, EGPAF developed a performance-based contracting (PBC) approach under

which sites agree to deliver services according to predefined protocols and are funded in accordance with

their documented patient loads.

With EP-supported HIV/AIDS services scaling up and Cote d'Ivoire moving toward peace and stability,

EGPAF is now able to provide full support to project sites throughout the country. Strong monitoring and

evaluation of the whole program is essential to improve the quality of services, ensure that lessons learned

are disseminated, work toward sustainable models of service delivery that can eventually be taken over by

the MOH, and report the most accurate numbers possible.

EGPAF/Washington has finalized the development of a Web-based worldwide HIV/AIDS database (called

GLASER) to monitor PMTCT, treatment, and care programs that EGPAF implements in 17 countries. Data

from April-June 2007 is the first to be entered directly into the database via Internet. Based at each

country's EGPAF headquarters, the database collects site and partner characteristics in addition to

standard M&E indicators. It allows data-quality improvement with built-in quality checks and generates

standard and ad-hoc reports at site, district, and country level for performance assessment and use for

program improvement.

In Cote d'Ivoire, EGPAF will support the rollout of a national electronic tool, and when the new national tool

is effective, EGPAF will develop a specific module to link the national electronic tool with GLASER.

Standard and ad-hoc reports will continue to be generated through GLASER and will feed back to sites and

districts for use for program improvement. FY08 funding will be used in part to adapt the GLASER database

to produce all of the Côte d'Ivoire-specific reporting required by partners, including the MOH department in

charge of data management.

In FY07, EGPAF has supported 25 health districts to be computerized for data management, and five

individual ART sites have implemented a temporary database for the longitudinal follow-up of patients and

program management while waiting for the finalization of a national tool. Ten health districts have received

telephones and Internet for data transmission, and seven districts have received motorcycles to collect data

from far-flung sites. EGPAF has also supported significant training in the area of SI, including training 25

health districts in epidemiologic data collection and conducting seven training sessions with health districts

on the importance of feedback throughout all levels of the health system and on working through

mechanisms by which regional and district health authorities can communicate such information

downwards.

The need for EGPAF's performance-based sub-partners to track patient visits closely, coupled with the

generally poor quality of patient records in the country, has led EGPAF to develop a series of patient record

forms, each linked to a particular type of visit, and an accompanying database that will allow both grant

recipients and EGPAF to follow program progress closely, with the added benefit of allowing for computer-

based quality-assurance approaches. (EGPAF's current QA approach depends on the random selection of

a sample of patient records on site). This patient record monitoring approach is being piloted at five sites

and will roll out to all sites supported by performance-based contracts in FY08. Despite encouraging results,

many challenges remain:

1) The absence of indicators that permit longitudinal follow-up of mothers and children identified as HIV-

positive in PMTCT

2) A lack of standard registers or standard patient records

3) A lack of a consistent referral system allowing tracking of referrals and counter-referrals

4) Difficulty in determining ART patient status (deaths, drop-outs, and transfers) due to the lack of a unique

patient identifier

5) A lack of systematic approaches to data collection on laboratory activities

6) A lack of computerization at site level

7) A lack of personnel devoted to M&E at the district and site levels

FY08 funds in the program area of SI will be used to conduct the following activities:

EGAPAF Country Team Activities

In collaboration with the USG country team, national counterparts, and other PEPFAR partners, EGPAF SI

officers will:

1) Participate in adapting country data-collection tools (paper and electronic).

2) Provide ongoing technical support and training to data clerks.

3) Train EGPAF multidisciplinary care teams on how to use program data to assess the quality of care at

their sites.

4) Provide semi-annual and annual program results and ad hoc data sets as requested by the USG team.

5) Participate in quarterly SI meetings organized by the USG strategic information branch and implement

decisions made during these meetings.

6) Submit articles to peer-review journals.

Site- and District-Level Activities

EGPAF will:

1) Hire, orient, and continually train and supervise site-level data clerks as necessary.

2) Provide data-processing equipment and supplies (computers and accessories) to sites and health

districts; provide and train staff in the appropriate software for each type of service; equip pharmacies and

laboratories with computers and adequate software for HIV commodities management; provide needed

logistical support for data collection and transmission; provide M&E tools (registers and other materials) at

site and district levels; and provide transportation and IT equipment needed for M&E activities (Internet,

photocopiers, phone cards, motorbikes, bikes, fuel, etc.). EGPAF will maintain the wireless network installed

in the university hospital complex (CHU) of Treichville, with expansion to CHU-Cocody and the TB center

(CAT) in Adjamé, and will computerize patient records at the CHU-Treichville with technical support from

UCSF.

Activity Narrative: 3) Continue training in M&E and quality assurance.

Strengthening of National SI Activities

In support of the national SI system, EGPAF will:

1) Provide training and strong support to district teams responsible for data recording and transfer,

electronic recording and processing, and reports editing. District teams will prepare monthly reports that

include information related to all aspects (quantitative and qualitative) of EGPAF's program. Reports will be

sent to the regional level and to the National HIV/AIDS Care and Treatment Program (PNPEC) to feed into

national data-collection efforts.

2) EGPAF will expand data-quality improvement activities with technical assistance from JSI and in close

collaboration with the EP SI team and district data managers.

3) Collaborate with the PNPEC and other partners to use a unique patient identifier to follow patients

through time and space.

5) Feed commodities data into the national data-collection system for drug and supply-chain management.

The patient-management system being used at all sites will be interfaced with the Partnership for Supply

Chain Management system, which will monitor all care and treatment commodities data for EP programs in

Cote d'Ivoire.

6) Organize regular working sessions with the MOH and other key stakeholders for the deployment of tools

for data management at all EGPAF-supported sites.

EGPAF will work closely with other SI partners - including the MLS and MOH data-management divisions

for the development of national data-collection software as well as JSI, ISPED-Bordeaux, ACONDA, and

ICAP-CU - while providing specific technical and logistic support at district and site levels, including

ensuring availability of all validated M&E tools.

To promote sustainability, the hiring of staff will be conducted in close collaboration with the MOH and other

government decentralized entities (mayors, general councils).

Since 2004, the USG has funded the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to assist the

Ministry of Health (MOH) in supporting and expanding HIV/AIDS care and treatment and PMTCT programs

while building on and complementing other programs supported by PEPFAR, the Global Fund, UNICEF,

and others. Policy work has been an integral part of this expansion.

EGPAF supports program implementation through a variety of sub-recipients (NGO/CBO/FBO/private-

sector partners) to provide HIV services in the health sector. These partners face diverse organizational

challenges in achieving service-delivery goals and meeting USG reporting requirements, largely due to a

lack of experience in HIV/AIDS program implementation and/or weak administrative and financial

management systems. Building the technical and organizational capacity of these sub-grantees remains a

high priority in the pursuit of sustainable quality services in Cote d'Ivoire.

EGPAF initially supported its local partners largely through cost-reimbursement grants but quickly saw

varying output-to-cost levels and a lack of a strong drive to expand services since there was no direct

relationship between the level of funding they received and the number of clients they served each quarter.

In response to this problem and the need to support smaller CBOs and FBOs with no USG financial

accounting experience, EGPAF developed a performance-based contracting (PBC) approach (modeled on

the USG fixed obligation grant model) in which sites agree to deliver services according to predefined

protocols and are funded in accordance with their documented patient loads.

This approach essentially pays recipients for services delivered and does not require the recipient

organization to have as comprehensive an administrative or financial structure supporting the grant

agreement. This makes awarding the grants significantly easier. However, EGPAF notes that smaller civil-

society sites still need significant training in administration, financial management, stock management and

forecasting, and M&E to deliver consistent high-quality services. EGPAF has been dealing with these issues

largely through technical assistance but is moving toward a more formalized training approach that would

cover more civil-society partners.

With FY07 funding, EGPAF has:

• Signed MOUs with the faculty of medicine of the University of Abidjan and the social workers training

school and is close to signing an MOU with the pharmacy faculty. These agreements aim to address issues

such as the lack of HIV/AIDS service-delivery training for young physicians, social workers, and

pharmacists and the fact that there is a one-year gap between completion of training and employment in the

public sector. EGPAF is integrating an HIV prevention, care, and treatment curriculum focused on service

delivery as an option for students in the last year of their studies, coupled with a 6- to 12-month internship at

EGPAF sites. The first 100 students to take advantage of this program will be sent out to 25 EGPAF-

supported sites in mid-September 2007, greatly expanding the technical knowledge of HIV/AIDS service

delivery at these sites.

• Contracted with GROFORMED (an association of infectious-disease specialists) and the pediatric health

professional association to develop a mentorship and preceptorship training curriculum to be used

throughout EGPAF's program, mostly for in-service training (but also applicable for pre-service training).

The pediatricians association has developed the first pediatric HIV care and treatment guidelines validated

by the MOH for further training of pediatric-care providers. GROFORMED is on track to finalize guidelines

for routine testing in clinical settings and the first national preceptorship, attachment, and refresher training

curriculum, to be validated soon.

• Developed a curriculum and instituted training for performance-based contract recipients on the concepts

and requirements of such awards.

• Initiated planning of three workshops on USG funds management for its sub-grantees, with training in

specific technical areas such as proposal development, strategic planning, and monitoring and evaluation

for health programs.

• Conducted orientation and training workshops for the administrative and management staff of health

professional associations (SIPE, SIPIT, SOGOCI, SIP, GROFORMED) to reinforce their administrative,

financial, and program management capacities in support of their role in network development, training, and

service delivery.

The need for EGPAF's performance-based partners to track patient visits closely, coupled with the poor

quality of patient records in the country in general, has led to the development of a series of patient record

forms, each linked to a particular type of visit, and an accompanying database that will allow both the grant

recipients and EGPAF to follow program progress closely, with the added benefit of allowing for computer-

based quality-assurance approaches. This patient record/PBC monitoring approach is being piloted at five

sites and will be rolled out to all PBC-supported sites in 2008.

EGPAF is also pursuing demonstration projects in Agnibilekro and Dimbokro to fund the public sector, either

through the health district or through local government (conseil general), under the leadership of the MOH,

the Ministry of the Interior, and the Ministry of Finance.

FY08 funds will be used to continue and expand these activities to strengthen civil-society HIV/AIDS service

-delivery organizations in Côte d'Ivoire by:

• Continuing to reinforce EGPAF subgrantees' technical and project-management capacity.

• Pursuing partnerships with health professional training institutions through the provision of scholarships to

attend the university diploma course on HIV, TB, and malaria management developed in partnership with

the University of Abidjan.

• Providing modern teaching equipment to these institutions and refurbishing the amphitheater of the faculty

of medicine at the University of Abidjan.

• Purchasing IT equipment for various training partners conducting these activities.

• Sharing lessons and tools with government ministries and other USG partners that are providing sub-

grants to local NGOs.

• Collaborating with the national network of PLWHA organizations, JHPIEGO, and Abt Associates, in

partnership with the Ministry of Labor and the Ministry of Professional Teaching, to advocate for the

establishment of a "certificate of professional competency" for PLWHA working as lay counselors, to

facilitate their recruitment and employment by the government. This will be a major step toward resolving

the issue of sustainable employment for PLWHA working as volunteers and supported by PEPFAR

partners.

Ongoing and new activities complement EGPAF's work in both the public and private sectors to strengthen

Activity Narrative: national capacity by setting up well-performing commodity and data management systems. EGPAF also

complements the work of other USG partners in building community-level or decentralized capacity,

mobilizing resources, and empowering communities to mobilize wraparound resources to improve the

sustainability and complementarity of HIV services.

All of these activities are being conducted in close collaboration with Ivorian ministries and other USG

partners. They thus help pave the way for a sustainable program as they institutionalize activities that are

currently undertaken on an ad hoc basis, and they greatly strengthen civil society, weakened after eight

years of conflict, to step into its proper role in Côte d'Ivoire. EGPAF will strive to ensure that lessons learned

will inform MOH strategies for sustaining HIV programs at the end of the project.