PEPFAR continues to target populations most at risk for HIV acquisition and transmission in order to affect

HIV transmission dynamics and provide care to those most in need. In Cote d'Ivoire, with its prolonged

political and military crisis, the USG team targeted uniformed services and their sexual partners for special

attention.

In 2005, PSI and its partners (AIMAS, CARITAS, ESPOIR FANCI and JHPIEGO) were funded to implement

a PEPFAR project to expand HIV prevention, counseling and HIV testing, and care interventions targeting

the uniformed services, ex-combatants, and their partners in Cote d'Ivoire. The project seeks to address

negative gender and sexual violence norms, promote sexual risk reduction especially emphasizing partner

reduction, condom use and promoting uptake of HIV testing and STI and HIV care and treatment services

including secondary prevention for HIV positive persons and within HIV discordant couples. This strategy

includes prevention interventions targeting child soldiers that are adapted to their age, sexual experience

and context, which are conducted in collaboration with UNICEF.

With PEPFAR funds, PSI has coordinated with the Ministry of Defense, rebel forces and other partners

(UNFPA and UNICEF), and the national disarmament, demobilization and reinsertion program (DDR) to

conduct a national needs assessment. With these data the project has identified 40 intervention sites (20 in

the Northern zone controlled by the Forces Nouvelles, and 20 others in the southern government-controlled

zone) as well as 14 "Centers for Transit and Orientation" (CTO) for child soldiers (as part of the larger

national programs). Ten more sites (five in the North and five in the South) are being identified in

September 2007.

With FY05-06 funds, PSI sub-partner CARITAS took the lead in implementing the project's "AB"

interventions, working closely with the Ministry of AIDS (MLS) as well as national and international technical

partners (JHU/CCP, UNICEF, UNFPA, ONUCI and NCDDR). They have developed curricula and behavior

change communication (BCC) tools for child soldiers and children otherwise associated with the military.

They have also defined a baseline package for selected CTO sites and trained 20 trainers/supervisors, 104

community animators among local NGOs members, and 920 peer educators among adult soldiers.

PSI has launched a sustained communication campaign that promotes sexual risk reduction including

abstinence and the promotion of sexual health (among children) and partner reduction (for adults). Gender,

stigma reduction and CT promotion are additional themes integrated into the campaign, which has reached

a total of 200,680 individuals by March 2007 and is expected to reach a total of 404,958 individuals by

March 2008. Interpersonal communication activities based on participatory approaches are being conducted

through peer education and are reinforced by mass communication at military sites using mobile video

units. All communications materials are developed and validated with the involvement of the government

(Ministries of Defense, Internal Security, Health, HIV/AIDS, Education, Family and Social Affairs, among

others) as well as international organizations (UNFPA, ONUCI, PNDDR, CDC) and key implementing

partners such as JHU/CCP, FHI, REPMASCI, ARSI, COCCI, RIP+, CARE, and Alliance. The focal point of

each army (both Northern and Southern) will also visit selected PSI military projects in FY07 to share best

practices with colleagues in other countries.

A national disarmament, demobilization and reinsertion program has been planned for both child and adult

soldiers and rebel forces. UNICEF has announced that all CTO sites will close down by December 2007,

with all child soldiers being reintegrated into their communities. Therefore, the project will shift its target

group from child soldiers to children of uniformed personnel.

With FY08 funds, the project will build upon previous project activities and successes to continue to rapidly

expand service delivery and prevention interventions in the existing project sites. With FY 08 funds, key

project AB activities include:

For children - ages 8-14:

- Identification of children of uniformed personnel

- Collaboration with uniformed personnel spouses' associations/NGOs to conduct AB activities among

identified children. This will include providing training and technical support to associations of military wives

to assist them with carrying out awareness and behavior change activities promoting AB as well as other

prevention methods as appropriate. The goal of this activity is to empower and encourage mothers (and in

turn their partners) to engage in HIV/AIDS prevention activities with their children within the context of

military families.

- Training members of theses associations/NGOs as community-based educators to delivery AB messages

to children

- Behavior change communication activities via peers and influential elders

- Production of AB radio spots based on the project's mini films produced in FY 07. These spots will be

aired on local radios and will be used during site activities.

For older and sexually experienced children, adult military, and their partners, key FY08 activities will

include:

- Promoting HIV prevention measures, including the importance of partner reduction, mutual fidelity,

knowledge of one's serostatus, and positive sexual health, including gender issues. A variety of approaches

will be used to promote HIV prevention, many of which will be based on results from PSI's formative

research study (TRaC). Issues involving social norms and beliefs will be addressed using mass media tools

(posters, flyers, radio spots, etc.) designed to shift perceptions and attitudes on issues such as fidelity,

discrimination of PLWHA, sexual violence and coercion. These tools will be augmented by efforts to involve

key community leaders and influential members of the target groups to further shift social norms. These

approaches will be complemented by interpersonal communication activities (IPC) designed to address

individual attitudes and behaviors, thereby enhancing risk perception, self-efficacy, and other key behavioral

determinants. These IPC activities will be conducted by peer educators.

- Refresher training for the 50 adult supervisors and 500 peer educators to deliver effective HIV prevention

messages to the target population. Training will cover the full range of issues related to HIV/AIDS

prevention, including an important module on how peer educators can address gender issues, including

rape and sexual coercion with relation to HIV/AIDS.

- Producing AB radio spots based on the project's mini films produced in FY 07. These spots will be aired

on local radios and used during site activities

- Promoting "positive prevention" among PLWHA. These activities will include assisting PLWHA to protect

their sexual health, avoid newly acquiring STIs, delay progression of the disease, and avoid transmission of

Activity Narrative: HIV to others. This will be achieved via self-help groups that will promote couples testing, the adoption of

healthy behaviors, and HIV status disclosure.

In addition PSI will:

- Continue regular internal and quarterly external supervisions, with standards of performance tools, to be

validated on the national level. To further motivate project partners, quarterly awards and recognition will be

given to those sites delivering high-quality services. Quality will be determined by supervisors using

standardized evaluation forms. Each quarter, the top three performing sites will receive an award.

- Continue to coordinate activities with important national and local authorities. PSI has held coordination

meetings regarding prevention and CT activities with UNFPA, ONUCI, PDDR, and the UNDP post-crisis

unit. PSI will make available its trained peer educators for conducting sensitization activities within the DDR

sites. Similarly, PSI will continue to involve the district and regional health departments (DD and DR) as well

as the military hierarchy in monthly planning of activities in their respective areas, as well as in supervisory

activities. PSI's site supervisors will participate in meetings of the decentralized health committees

organized by the DD and DR, and all research data and program results will be shared with these

institutions.

- Perform a TRaC survey to monitor prevention activities and measure project impact over time.

The project promotes sustainability through the creation of a pool of trainers, peer educators, community

animators and military supervisors able to carry out activities well after the completion of the project. The

project will also work with the Ministry of Defense to further decentralize project management through the

creation of local and regional focal points in the fight against HIV/AIDS. /AIDS. The project will ensure

monitoring of the execution of the Ministry of Defense consolidated HIV plan as well as the sustainability

plan developed in 2006. These efforts include ensuring that all project activities are included in the

military's future budget and workplans so that project activities can continue into the future.

PSI will expand sexual-prevention interventions targeting mobile and other high-risk populations along

major trucking routes, including frontier towns, building on the successful regional PSAMAO project funded

through USAID and complementing the World Bank-funded coastal Corridor project.

Cote d'Ivoire remains the major hub of the West African region, characterized by high mobility of people,

due mostly to economic integration and opened borders, while at the same time suffering a period of

political, military, and economic instability. To mitigate the spread of HIV associated with highly-mobile

populations, cross-border interventions targeting core and bridge groups and populations along the main

migratory routes have been identified as national and regional priorities.

"Prevention du SIDA sur les Axes Migratoires de l'Afrique de l'Ouest et du Centre" (PSAMAO) was started

under the previously under USAID and covered four countries and was subsequently expanded into 17

countries.

PSAMAO is a best-practice program designed to encourage the adoption of safe and responsible sexual

behaviors among truckers, sex workers, customs and uniformed officials, and other high-risk and mobile

populations. The program includes behavior change communication (BCC) activities, social marketing of

condoms, treatment for sexually transmitted infections (STI), and voluntary counseling and testing (VCT)

promotion and referrals. Recent studies conducted by the PSAMAO regional project showed that from

March 2005 to November 2006 the consistent use of condoms by commercial sex workers with paying

clients rose from 44% to 53%. Among truckers, the rate of consistent condom use was 36% in March 2005,

and by November 2006 this had risen to 77% with occasional partners and 66% when paying for sex. The

survey also showed that use of condoms during last sexual encounter among both commercial sex workers

and truckers increased significantly with exposure to PSAMAO activities, regardless of the type of partner

(regular, occasional, or commercial) outside of an established partnership.

Studies have indicated that condom use is inconsistent among truck drivers and sex workers in the region,

suggesting a need for consistent program intervention. Cote d'Ivoire's 2006-2010 National Strategic Plan

identified prostitution, non-systematic use of condoms, migration, and mobility of people as determinants of

the HIV epidemic in Côte d'Ivoire.

PSI received USAID funding through the SFPS and WARP projects from October 2003 to September 2006

to implement the PSAMAO regional project in Côte d'Ivoire. Two local NGOs, Croix Rouge de Cote d'Ivoire

(targeting truck drivers) and SidAlerte Cote d'Ivoire (targeting sex workers), benefited from capacity building

to carry out activities at eight sites identified by the project: two in Abidjan and one each in Bouaké,

Korhogo, Ouangolodougou, Pogo, Man, and Danané. Within these organizations, two focal points, 14

ground supervisors, and 28 community-based educators were trained in behavioral change communication

based on a participatory approach. As of November 2006, it was estimated that there were a total of 1,075

commercial sex workers and 1,702 truckers being reached with communications activities across the 8

PSAMAO sites. Along with exposure to HIV/AIDS behaviour change communications activities, these

populations also are referred to institutions providing CT and STI services. The PSI project also ensures

access to affordable condoms in and around these PSAMAO sites, with over 87% of commercial sex

workers and truckers at these sites claiming to have been exposed the PSAMAO communications activities.

An estimated 5,000 truck drivers and sex workers a month were educated about partner reduction and

correct and consistent use of condoms and given access to CT, STI, and family-planning services (included

in this figure are many individuals receiving multiple exposures to messages and activities). Two health

centers in Abidjan participated in a training program on STI syndrome management and were provided with

STI syndromic treatment kits.

With FY07 EP funds, PSI is extending these interventions to new sites on the border and in the interior of

the country, for a total of 22 intervention sites. Target populations include truckers, sex workers, customs

and uniformed officials, and "migrant" populations.

With FY08 funding, PSI will continue to implement the range of PSAMAO behavior change communication

interventions including gender-based training focusing on sexual violence, alcohol, vulnerability, and

condom negotiation activities by community-based educators, and these activities are being expanded to

customs and other officials (formal and informal) at 14 border crossing zones.

Specific activities that will be undertaken in FY08 include :

- Ensuring the continued implementation of the project's communications activities by community educators

and supervisors targeting sex workers and their partners (including transactional sex workers such as

waitresses, bartenders, and ambulatory sellers). These peer and community educators will conduct

interpersonal communications activities (IPC) as well as mass media events at bus stations, border crossing

points, associated bars and restaurants and other areas where large numbers of the target populations

congregate, as well as within identifiable brothels and hotels used for transactional sex. IPC and mass

media activities will be complemented by the distribution of flyers and posters in high-trafficked areas by

community educators.

- Delivering the project's behavior change communications messages via interpersonal communication

activities and public demonstrations using the project's mobile video unit in all existing 22 PSAMAO project

sites.

- Ensuring the continued availability and re-supply of condoms across all condom access points that have

been created in conjunction with the condom social marketing project implemented by AIMAS.

- Supervising and reinforcing the diagnosis and testing for STIs in the 14 sites identified in FY07

- Supervising and reinforcing local NGOs sub-contracted to implement PSAMAO activities across the

various project sites.

- Reproducing and distributing a wide variety of communications materials developed in FY07, in

collaboration with JHU/CCP and the national BCC technical working group.

The relevant district and regional health departments (DD and DR) will play an important role in identifying

project intervention sites within their geographic regions, as well as being implicated in the monthly and

quarterly project planning activities. PSI's site supervisors will participate in the decentralized health

committee meetings held by the DD and DR, and will also invite DD and DR representatives to participate in

regular supervisory activities. PSI will also share with the DD and DR all results from activity

implementation and surveys conducted in their respective geographic areas.

Activity Narrative:

The project will promote sustainability by working through CBOs and other local public and private

organizations as well as building capacity of local participants at various levels (community workers,

supervisors, and health-service providers). PSI will also seek to participate in relevant coordination forums

at local, regional, and national levels, complementing activities of EP and other partners.

Commodities (condoms, STI kits) will be procured through existing distribution channels, in coordination

with national authorities.

PSI 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, PSI will participate in quarterly

SI meetings and will implement decisions taken during these meetings.

PEPFAR targets populations most at risk of HIV transmission in order to affect HIV transmission dynamics

and provide care to those in greatest need. In Cote d'Ivoire, which is undergoing a prolonged political and

military crisis, the USG team has targeted uniformed services and their sexual partners for special attention.

Since 2002, the country has seen active mobilization and deployment of various uniformed services

(national army, gendarmes, and police) as well as rebel forces. Increased mobility with separation from

spouses, economic disparities with the surrounding population, and crisis-related shifts in perceptions are

likely to contribute to heightened sexual risk behaviors among these populations. Access to information,

counseling and HIV testing, and health care is limited for uniformed services on active deployment.

In 2005, PSI and its partners (AIMAS, CARITAS, Espoir FANCI, and JHPIEGO) applied successfully to

implement an EP project to expand HIV prevention, uptake of counseling and HIV testing, and care

interventions targeting the uniformed services (including child soldiers) and their partners in Cote d'Ivoire.

Increased access to and uptake of combined prevention, sexually transmitted infection (STI) diagnosis and

treatment, and CT interventions in these populations is intended to lead to safer sexual behaviors, including

abstinence, fidelity, and, for populations engaged in high-risk behaviors, correct and consistent condom

use, as well as increased use of HIV care, treatment, and support through a strong referral network to

complementary services.

The campaign is designed to increase correct and consistent condom use among those engaged in high-

risk behaviors as part of a comprehensive ABC prevention strategy; to reduce high-risk behavior and

stigma; and to improve perception of personal risk, including the negative effects of alcohol consumption on

HIV-infection risk and ART adherence. Activities include training of peer educators to promote HIV

prevention, counseling of other prevention methods, dissemination of prevention methods via mass media

and group events, diagnosis and treatment of sexually transmitted infections (STIs) and condom sales in

high-risk areas.

To implement the project, PSI collaborates with and provides support to the National Security and Defense

Forces, Ministry of Health, and other government agencies, including helping to develop and implement

training and communications materials for peer educators. PSI's implementing partner AIMAS is

responsible for creating condom sales points in high-risk areas and ensuring condom promotion and

accessibility to high-risk target groups, while JHPIEGO has trained and supervised providers for the

diagnosis and treatment of STIs. Espoir FANCI works to reduce stigma through PLWHA testimonials and

peer education. PSI and its partners work to link activities with other HIV prevention, care and treatment,

and social services in the area.

Project activities complement and build on other EP-funded efforts, including Ministry of Health and FHI

development of a palliative-care policy and guidelines for clinic- and home-based care as part of a

continuum of care, as well as prevention, care, and treatment activities by other ministries (AIDS,

Education, Social Affairs), ANADER (in rural areas), CARE International (in underserved northern and

western areas), Alliance CI, and EGPAF. Activities are coordinated with the Ministry of Defense. All

communications materials are developed and validated with the involvement of the government as well as

international organizations (UNFPA, ONUCI, PNDDR, CDC/PEPFAR) and key implementing partners such

as JHU/CCP, FHI, REPMASCI, ARSI, COCCI, RIP+, CARE, ANADER, and Alliance. PSI also collaborates

with CARE, Alliance, EGPAF, and ACONDA and other partners to ensure a continuum of care for those

testing HIV-positive.

For FY08, the project proposes to continue and reinforce the current activities. In particular, FY08 activities

will include:

- BCC activities via interpersonal communication (IPC) techniques as well as mass media promoting other

means of HIV/AIDS prevention. Issues involving social norms and beliefs will be addressed using a

combination of mass media tools (posters, flyers, radio spots, etc.) designed to shift perceptions and

attitudes on issues such as fidelity, discrimination of PLWHA, sexual violence and coercion. These tools

will be augmented by efforts to involve key community leaders and influential members of the target groups

to further shift social norms. These approaches will be complemented by IPC activities designed to address

individual attitudes and behaviors, thereby enhancing risk perception, self-efficacy, and other key behavioral

determinants. IPC activities include small group sessions led by a peer educator, with each session

touching on key issues such as risk perception, partner reduction, correct condom use, stigma, the negative

affects of drug and alcohol use in relation to HIV, and the promotion of VCT. Peer educators use a variety

of interactive strategies, such as games, role-plays, and discussions of educational films, to achieve

sustained behavior change among the target group. These IPC activities will be conducted by peer

educators and community-based educators and will reach a total of 317,440 individuals with messages on

other means of prevention.

- Refresher training of the project's peer educators and supervisors charged with conducting

communications activities promoting correct and consistent condom use and other means of HIV/AIDS

prevention among the 50 project sites. Training will cover the full range of issues related to HIV/AIDS

prevention, including an important module on how peer educators can address gender issues, including

issues of rape and sexual coercion with relation to HIV/AIDS.

- Management and re-supply of the 1,680 condoms sales points created during the previous years of the

project.

- Distribute 566,560 male condoms during IPC sessions, group events and CT sessions, including correct

condom use demonstrations

- Distribute 600,000 male condoms via these condom sales points

- Distribution of male condoms to new recruits and to uniformed personnel departing on peacekeeping

missions

- Production of radio spots based on these mini-films for diffusion via local radio stations. These spots will

address four key themes: correct and consistent condom use; the negative effects of stigma of PLWHA; the

benefits of VCT services for couples, and prevention measures for sero-discordant couples; and how

alcohol and drug use can increase risk of exposure to HIV.

- Promoting "positive prevention" among PLWHA. These activities will include assisting people with

HIV/AIDS to protect their sexual health, avoid newly acquiring STIs, delaying the progression of the

disease, and avoiding transmission of HIV to others. This will be achieved via self-help groups that will

promote couples counseling and testing, the adoption of healthy and safe behaviors, and will provide

assistance with announcing one's sero-status to partners and family members.

- Provision of training and technical support to HIV/AIDS "cellules focales" within the uniformed services

Activity Narrative: (military, police, gendarmes, customs, water and forests) to assist them with carrying out awareness and

behavior change activities promoting other prevention methods.

- Continued coordination with important national and local authorities. PSI has held coordination meetings

regarding prevention and CT activities with UNFPA, ONUCI, PDDR, and the UNDP post-crisis unit. PSI will

make available its trained peer educators for conducting sensibilization activities within the DDR sites.

Similarly, PSI will continue to involve the district and regional health departments (DD and DR) as well as

the military hierarchy in monthly planning of activities, as well as involving them in external supervisory

activities. In addition, PSI's site supervisors will participate in meetings of the decentralized health

committees organized by the DD and DR, and all research data and program results will be shared with

these institutions.

Impact of BCC activities will be evaluated via PSI's TRaC (Tracking Results Continuously) surveys. These

surveys are used to identify key behavioral determinants for specific behaviors (such as consistent condom

use or partner reduction), measure exposure to project activities, and follow the evolution of the adoption

and retention of the desired behaviors over time. Having received approval of the study protocol in early

FY07, PSI will conduct the baseline study in mid-FY07, with follow-up TRaC studies each year to measure

progress.

The project promotes sustainability through the creation of a pool of trainers, peer educators, community

animators and military supervisors able to carry out activities well after the completion of the project. The

project will also work with the Ministry of Defense to further decentralize project management through the

creation of local and regional focal points in the fight against HIV/AIDS. /AIDS. The project will ensure

monitoring of the execution of the Ministry of Defense consolidated HIV plan as well as the sustainability

plan developed in 2006. These efforts include ensuring that all project activities are included in the

military's future budget and work plans so that project activities can continue into the future.

PSI will continue to implement an M&E plan based on national and USG requirements and 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, PSI will participate in quarterly SI meetings and will

implement decisions taken during these meetings.

PEPFAR continues to target populations most at risk of HIV acquisition and transmission in order to affect

HIV transmission dynamics and provide care to those in greatest need. In Cote d'Ivoire, with the prolonged

political and military crisis, the PEPFAR team has targeted uniformed services and their sexual partners for

special attention. In 2005, PSI and its partners (AIMAS, CARITAS, Espoir FANCI, and JHPIEGO) applied

successfully to implement a PEPFAR-funded project to expand HIV prevention, counseling and HIV testing,

and care interventions targeting the uniformed services, ex-combatants, and their partners in Cote d'Ivoire.

In the program area of palliative care, the project aims to provide comprehensive care, including health

care, psychosocial support, and appropriate referrals to people living with HIV/AIDS (PLWHA). Linkages

with HIV prevention, CT, ART, and OVC services are emphasized. Activities are guided by the new national

palliative-care policy and guidelines and the 2006-2010 National HIV/AIDS Strategic Plan and Palliative

Care Strategic Plan.

Identifying individuals in need of palliative care is part of a community-based strategy that begins with HIV

education and CT. Peer educators raise HIV/AIDS awareness among the target population, addressing

issues such as fidelity, condom use, discrimination against PLWHA, sexual violence, and coercion. Peer

educators stress the importance of knowing one's sero-status, and people interested in getting tested are

referred to CT services. The CT counselor records the names of those testing positive and puts them in

touch with a community-based educator trained in providing psychosocial support. The client's children are

referred for health-care services, if needed, and other services for OVC. The project uses national referral

procedures to refer all HIV-positive clients to care and treatment services. The counter-referral is addressed

back to the site counselors.

FY06 activities include needs assessments and selection of 40 intervention sites for adult soldiers (20

military camps in the North and 20 in the South) and 15 transit and orientation centers (CTO) for child

soldiers. (In line with a national disarmament, demobilization, and reinsertion program planned for both child

and adult soldiers and rebel forces, UNICEF has announced that all CTO sites will close down by

December 2007, with all child soldiers being reintegrated into their communities, so the project will shift its

target group from child soldiers to children of uniformed personnel.) Resource trainers from RIP+ (a national

network of PLWHA organizations) have conducted training of trainers for members of Espoir FANCI, an

NGO of military members living with HIV, in psychosocial support based on peer counseling. These trainers

in turn train members of Espoir FANCI, who act as counselors providing psychosocial support and

assistance with referrals to available treatment and care services.

Since Espoir FANCI does not have access to sites in the North, RIP+ will help PSI identify two local

northern NGOs of PLWHA, whose members will be trained to provide palliative care to members of the non-

government armed forces in the northern zone. Counselors in all project sites provide support to PLWHA

through home and workplace visits, encourage treatment literacy and observance, organize support groups

with military authorities, conduct awareness activities to reduce stigma and discrimination, and strengthen

networking with other PLWHA organizations. Counselors are also trained to refer PLWHA to appropriate

health and other services and to update the mapping of palliative-care units, treatment centers, and OVC-

care units.

In addition to psychosocial support and referral services, the project provides PLWHA with "positive-living"

kits containing insecticide-treated nets, a potable water system, oral rehydration salt, condoms, a positive-

living guide, and, starting in FY08, cotrimoxazole. Counselors promote HIV prevention for PLWHA through

use of the kit, such as teaching correct and consistent condom use. For each kit distributed, the project

provides social support for at least three people (the PLWHA, a partner, and a child).

The project encourages systematic testing of PLWHA partners and families. This is done beginning with the

post-test counseling sessions and within the project's self-help groups. Anyone testing HIV-positive is

administered a screening questionnaire for TB, and anyone suspected of having TB is referred to the

nearest TB center or health facility.

Project activities complement and build on other PEPFAR-funded efforts, including development of palliative

-care policy and guidelines for clinic- and home-based care as part of a continuum of care as well as

prevention, care, and treatment activities by ministries (AIDS, Health, Education, Social Affairs), ANADER

(in rural areas), CARE International (in northern and western areas), Alliance CI, and EGPAF. Activities are

coordinated with the Ministry of Defense.

In FY07, the project is expanding to a total of 50 adult sites, as well as 22 sites of PSI's PSAMAO project

(HIV/AIDS interventions targeting truckers and commercial sex workers), and is expanding project activities

(prevention communication, CT, palliative care) to other uniformed services (police, customs, and forest

rangers). This expansion will involve meeting with the leadership of these services to present the strategy,

identify appropriate intervention sites, and identify individuals to be trained as peer counselors and

educators.

The number of PC clients identified by the project has been low, with a total of 140 PLWHA at the end of

June 2007, due in part to delays in launching the project and training partner NGOs. In FY07, PSI is adding

measures to reinforce its PC strategy, including training health-care providers at the project's integrated

testing sites to provide PC services and "positive living" kits. In FY07, the project expects to provide PC

services for 1,682 PLWHA.

FY08 funding is requested to continue and reinforce the project's palliative care activities, including

providing PC services to 2,000 PLWHA. Other activities will include:

1. Award 11 sub-contracts to regional HIV/AIDS committees of the uniformed services (military, gendarmes,

police, customs, water, and forests) to contribute to decentralization of prevention and care activities of the

uniformed services. The activities of counselors and supervisors at the sites will be integrated into the

annual work plan of the regional uniformed services committee (which PSI will help to develop and

implement) to help build sustainability.

2. Conduct refresher training for counselors providing palliative care services.

3. Train all counselors to identify OVC and refer them to specified OVC service providers at the site.

4. Conduct ongoing supervision of each partner NGO implementing palliative care activities.

5. Constitute and distribute 2,000 palliative care kits with products procured by SCMS.

Activity Narrative: 6. Renew contracts for delivery of palliative care packages with local NGOs that have proven themselves

capable of implementing this activity. The project will continue to identify and train additional NGOs to

ensure proper coverage of all project sites.

7. Refer PLWHA to health centers for additional care and treatment as needed.

8. Supervise counselors providing CT and PC activities. The project sites will have 20 trained supervisors to

monitor the work of peer counselors, which will be complemented by two mobile supervisory teams staffed

by experienced PSI supervisors, who will visit all project sites on a rotating basis.

In FY08, it is expected that the country will continue to move toward full political reconciliation. The process

of disarmament, demobilization, and reinsertion of military forces began in FY07, and PSI has held

coordination meetings with the UNDP post-crisis unit regarding HIV prevention and CT activities. Once

reunification occurs, PSI will work with the Ministry of Defense to identify and locate all military personnel

trained as part of the PSI-PEPFAR program so as to capitalize on their skills to continue implementation of

HIV/AIDS/STI activities. Similarly, PSI will continue to involve the district and regional health departments as

well as the military hierarchy in monthly planning of activities, as well as in external supervisory activities. In

addition, PSI's site supervisors will participate in meetings of the decentralized health committees organized

by the district and regional health departments.

The project promotes sustainability through the creation of a pool of trainers, peer educators, community

animators, and military supervisors able to carry out activities after the completion of the project. The project

will also work with the Ministry of Defense to further decentralize project management through the creation

of local and regional focal points in the fight against HIV/AIDS. The project will ensure monitoring of the

execution of the Ministry of Defense consolidated HIV plan as well as the sustainability plan developed in

2006. These efforts include ensuring that all project activities are included in the military's future budget and

work plans.

PSI 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 single national M&E system, PSI will

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

PEPFAR continues to target populations most at risk of HIV acquisition and transmission in order to affect

HIV transmission dynamics and provide care to those in greatest need. In Cote d'Ivoire, with the prolonged

political and military crisis, the PEPFAR team has targeted uniformed services and their sexual partners for

special attention. Since 2002, there has been active mobilization and deployment of various uniformed

services (national army, gendarmes, police). Increased mobility with separation from spouses, economic

disparities with the surrounding population, and crisis-related shifts in perceptions (e.g. gender and violence

norms, less concern about the long term, etc.) are likely to contribute to heightened sexual risk behaviors

among these populations. Access to information, counseling and HIV testing, and health care is limited for

uniformed services on active deployment. In addition, children have been victims of the conflict. A national

disarmament, demobilization, and reinsertion program has been planned for both child and adult soldiers

and rebel forces.

In 2005, PSI and its partners (AIMAS, CARITAS, Espoir FANCI, and JHPIEGO) applied successfully to

implement a PEPFAR-funded project to expand HIV prevention, counseling and HIV testing (CT), and care

interventions targeting the uniformed services, ex-combatants, and their partners.

Despite significant interest in CT among the armed and security forces, uptake remains low. In a 2004 PSI

survey among the Army of Cote d'Ivoire, 82% of respondents stated that they had the intention to get HIV

tested, yet fewer than 30% had done so. The main reason cited for not seeking a test was a lack of

medications to treat HIV/AIDS (66%).

To improve CT uptake among the target population, PSI is pursuing a dual strategy involving integrated

fixed CT services and mobile CT services. In FY06-07, the project developed integrated CT services at

three military health structures (reinforcing the existing CT center at the Military Hospital of Abidjan and

integrating new CT services in Daloa and Korhogo) and established two mobile CT units. By June 2007,

10,603 uniformed personnel and their partners had been counseled, tested, and given their results. By the

end of FY07, an additional eight integrated CT centers will be established, and it is estimated that 51,378

military personnel, police officers, customs agents, water and forest agents, and their partners will have

received CT services by March 2008.

A mapping exercise by region is being completed to define referral facilities, which will help PSI-supported

sites refer PLWHA to needed services (ART, PMTCT, psychological or nutritional management, OVC

services) within their geographic region.

At all project sites, CT services are part of a comprehensive continuum of care that includes providing

clients with information on HIV prevention during pre- and post-test counseling (including issues such as

partner reduction, correct and consistent condom use, and avoiding risk factors such excessive alcohol) as

well as providing referral to care, treatment, and support for those testing HIV-positive. All providers are

trained to encourage clients to have their partners tested, to provide CT services to couples, and to assist

sero-discordant couples in managing their status and avoiding sero-conversion. All providers will be trained

to identify OVC and refer them to appropriate services.

In FY08, activities will be informed by key lessons learned and sustainability strategies identified in previous

years, including the importance of training and retraining community counselors and peer educators; of

conducting regular supervision of these counselors and educators to ensure quality service delivery; of

repeated exposure to health messages, particularly in small-group or individual settings, to achieve

behavior change; of communication and coordination with our partners at the local, regional, and national

levels; and of finding ways to motivate community and peer educators.

Funding in FY08 will allow the project to reinforce activities begun in FY07 within the structure of the police,

customs, and water and forest departments and to move toward a more community-based testing strategy.

With the expected adoption of a simpler national algorithm allowing rapid tests with blood drawn from a

finger prick, PSI proposes to train the project's peer educators/counselors to conduct HIV testing in their

respective sites. This strategy will allow for the rapid scale-up of CT activities and ensure permanent CT

services at each program site, as opposed to having to wait for the periodic arrival of the mobile testing unit

and accompanying laboratory technician. This strategy will also help in promoting HIV testing among

couples.

Key interventions envisioned for FY08 include:

1- Awarding of 11 sub-contracts to regional HIV/AIDS committees of the uniformed services (military,

gendarmes, police, customs, water, and forests) to contribute to decentralization of prevention and care

activities of the uniformed services. The activities of counselors and supervisors at the sites will be

integrated into the annual work plan of the regional uniformed services committee (which PSI will help to

develop and implement) to help build sustainability.

2- Continuation of CT activities via integrated sites as well as community-based CT at sites previously

reached with the mobile testing unit, resulting in the testing of 37,120 individuals. Within the project's 11

fixed sites, CT will be proposed to all individuals coming to the health facility, making CT a routine,

integrated element of health-care services. At each of the project's 50 military mobile CT destinations, three

peer counselors (a total of 150) will be trained in the new algorithm and will be able to conduct CT functions

at their respective sites, thus eliminating dependence on the arrival of the mobile testing units.

3- Continuation of promotional activities surrounding CT, with an emphasis on couples counseling.

Promotional activities will include using mass media to raise awareness of the benefits and availability of

CT, as well as interpersonal communication by peer educators and counselors.

4- Training of 66 counselors at the 11 integrated sites in HIV testing using the new algorithm. Counselors

and lab technicians will be trained in counseling and finger-prick testing based on the new algorithm. Lab

technicians currently doing HIV testing via blood draws will also play a role in training and supervising the

community-based CT agents in applying the new algorithm.

5- Supervision of community-based and health center-based CT activities. The project's two mobile CT

units will be converted into supervisory units and will visit project sites on a regular basis to ensure quality

services. This will be complemented by the work of 20 supervisors drawn from the ranks of the military

health service, chosen in geographically representative areas so as to be able to provide regular

supervision at all 50 mobile CT destinations.

6- Quality control of testing procedures in collaboration with the National HIV/AIDS Care and Treatment

Program (PNPEC) via CDC/Projet RETRO-CI.

Activity Narrative: 7- To ensure proper and efficient referral processes, PSI will participate in updating the national directory of

services for PLWHA and in revising the mapping of all treatment and care facilities. Psychosocial care and

support for those testing HIV-positive will be provided by members of Espoir FANCI (an NGO of military

PLWHA) and 10 NGOs that are part of RIP+ (national network of PLWHA organizations). These NGOs will

provide self-help groups at project sites.

PSI will continue to involve the district and regional health departments and the military hierarchy in the

monthly planning of activities in their areas, as well as in supervision activities three times a year. In each of

the 50 districts where there is a project site, PSI will train one district staff person to supervise CT service

delivery. In addition, PSI's site supervisors will participate in meetings of the decentralized health

committees organized by the district and regional health departments, and all research data and program

results will be shared with these institutions.

The project will promote sustainability through the creation of pools of military counselors, lab staff, and

supervisors who will continue their activities well after the project is completed. The project will also work

with the Ministry of Defense to further decentralize project management through the creation of local and

regional focal points in the fight against HIV/AIDS. All fixed testing sites will remain integrated within health-

care facilities managed by the military and other uniformed services, and the mobile CT units will revert to

the Ministry of Defense upon completion of the project. The project will ensure monitoring of the execution

of the ministry's consolidated HIV plan as well as the sustainability plan developed in 2006. These efforts

include ensuring that all project activities are included in the military's future budget and work plans.