Noted April 16, 2008:

This funding represents a percentage of Alliance CI 's OP funds reprogrammed to FHI to provide financial,

programmatic, technical and overall capacity building support to subpartners who received grants in FY 07

to continue providing uninterrupted OP services in the zones FHI is working. FHI will also provide subgrant

funding and technical assistance to several subpartners formerly supported through Alliance National

Contre le SIDA.

In FY07, FHI's Highly Vulnerable Populations Project (PAPO-HV) supported the strengthening and

expansion of sexual risk-reduction interventions as part of a comprehensive prevention, CT, and care

package of services targeting transactional sex workers (SW) and their partners. These interventions have

been carried out in 18 sites delivering behaviour change communication interventions targeting highly

vulnerable populations (HVP). The key results achieved at the 18 HVP prevention sites were:

- The distribution of 1,500,000 male and female condoms

- 40,000 individuals (mostly made up of SW and their partners) were reached through community-based

sensitization and HIV/AIDS prevention through behaviour change messages focusing on correct and

consistent use of condoms.

- 150 people were trained to promote prevention of HIV/AIDS among HVP, especially SW and their

partners.

During the same period, FHI supported the implementation of BCC Quality Assurance (QA) through the

dissemination of QA tools in the 18 HVP BCC sites and training 150 service providers on the use of the

tools. In addition, management and resources mobilization tools were disseminated at the national level in

collaboration with MLS. Extension and sustainability plans were revised and updated at the existing HVP

BCC sites to document progress achieved by the NGOs.

PAPO-HV Project continued to collaborate with other PEPFAR partners such as Alliance-CI for Capacity

Building and Assistance to NGOs and technical management of the VCT mobile units in order to provide

prevention and care services for difficult to reach SW in Abidjan and San Pédro.

With COP 08 funds, FHI will build on ongoing programs with technical and financial support while continuing

to provide sub-grants to the 18 existing implementing NGOs/sites. In addition, FHI will expand PAPO-HV to

seven (7) new communities through strategically selected sub-partners. The technical support FHI will

provide to new partners includes strengthening new service providers and reviewing progress and providing

supportive supervision in the implementation at each HVP site of the minimum package of services (MPS)

including BCC/prevention through peer education, CT, STI management, PC and ART.

PAPO-HV leveraged additional funding for this program from the Belgian Development Cooperation (BC)

for 2008. This funding will support operational research and scale up evaluation activities.

Technical support provided by FHI and its partners (ITM and Espace Confiance) to implementing partners

includes training of new service providers, dissemination and use of QA and M&E standardized tools,

regular participatory program reviews and supervision. To this effect, Espace Confiance (EC) will continue

to provide practical training sessions and coaching for health care providers in prevention, care and

treatment at Clinique de Confiance (CdC) site.

The PAPO-HV project will establish links with other PEPFAR partners such as Alliance, CARE and EGPAF

for the training of clinic service providers to expand beyond the 18 HVP BCC sites. PAPO-HV will conduct

studies related to condom use and STI prevalence as well as capture-recapture techniques for the SW size

estimation at the various sites. At the regional level, PAPO-HV will collaborate with the Institute of Tropical

Medicine (ITM) to exchange the project experiences achieved in Côte d'Ivoire with similar ones

implemented in Kisumu (Kenya) and Kinshasa (DRC).

More specifically, in FY08 FHI will:

1. Having completed the data collection and analysis on SW size estimation, FHI will support the increase of

BCC services coverage by 25%. This increase will be made through the selection of at least seven (7) new

BCC sites and/or the strengthening of existing sites according to pre established criteria, in collaboration

with MLS, MSHP/PNPEC, and other partners. In the selected sites, FHI will support BCC activities through

sub grants awarded in 2007 to newly identified NGOs/sites. The selection of new NGOs/sites is part of the

replication of HVP(SW) intervention models including the CdC model;

2. Continue to provide technical support to the 18 existing prevention sites implementing sexual risk-

reduction interventions towards HVP, especially SW and their partners;

3. Continue to improve the mapping of SW. Through the use of GPS tools and the « capture and recapture

» method, FHI will support quantitative data collection for reliable planning of field activities and a better

appreciation of the coverage of BCC interventions;

4. Continue to provide technical support to reinforce BCC activities prior to mobile CT and care services

offered by EC in Abidjan and APROSAM in San Pedro to sex workers living in difficult-to-reach areas. FHI

will also support availability of condoms in venues such as hotels and bars;

5. Improve coverage and quality of clinic-based and outreach prevention and CT-promotion activities

conducted by peer health educators and community workers. Specifically, FHI in collaboration with MLS

and MSHP, will support the standardization of BCC services for SW in the project sites, through the

dissemination of standardized tools (reference manual); strengthen the referral system to PMTCT, OVC and

ART programs (for HVP sites which do not currently have integrated ART). Prevention activities will address

stigma and sexual violence by providing HVP-friendly services, staff with nonjudgmental attitudes, and

conducting BCC activities for other HVP (partners, clients, bar owners);

6. Continue to strengthen the operational management of NGOs and existing associations through the

strengthening of administrative and financial management, budgeting, leadership, monitoring and

evaluation, and mobilization of resources. More specifically, FHI will continue to support the revision,

Activity Narrative: update, and dissemination of the quality-assurance tools developed in 2006 in collaboration with other

partners, to better evaluate the quality of services. The system will be part of the current program-

management system. Quality-evaluation activities will be performed periodically, in accordance with national

guidelines, to improve the quality of BCC and other prevention services;

7. Continue support (started in 2006) to EC, in collaboration with JHPIEGO, EGPAF, RETRO-CI and the

regional AWARE project, to create a national and regional training center for health care providers working

in settings dedicated to the prevention and care of STI/HIV among sex workers. The training centre -CdC-

will be linked to similar network service centres at the national and regional levels. More specifically, in

2008, EC will be responsible for implementing prevention and care activities at the centres for SW within

PAPO-HV, under FHI support, to begin to transfer primary responsibility to EC;

8. Continue to increase coordination among NGOs and associations by strengthening efforts and providing

technical assistance to the national government's working groups, particularly the Sex Work and HIV/AIDS

working group within the MLS, and the Technical Working Group on STI (GTT/IST);

9. Support the revision, after evaluation, of the extension plan of the project PAPO-HV. This plan was

elaborated in 2006, in collaboration with all key partners, and includes geographic extension to zones under

control of the New Forces as well as broadening the target population to occasional sex workers. A revised

plan will allow for reoriented interventions, including primary health services for HIV infected people, and by

expanding services throughout the country;

10. Support an annual evaluation of the sustainability plan of project activities. PAPO-HV is guided by a

sustainability strategy aimed at reaching the goals of the project while preparing local partners to assume

organizational and technical management functions and continue interventions at the end of the

CDC/Belgian Cooperation funding period;

11. Support ministries (MLS, MJ, MFFAS, MEN, MJDH, MIS) and local organizations (CBOs, FBOs, NGOs)

and associations, in collaboration with partners (PSI, Alliance, Care), to identify and develop strategies for

non traditional sex workers such as transactional sex populations who inconsistently enter sex work;

12. Support MLS and MSHP, in collaboration with key partners (PSI, Alliance, RIP+) to develop and

implement innovative prevention and care strategies for MSM;

13. Train health staff and focal points in outreach activities at all sites in the use of Quality Assurance tools.

FHI will also support the elaboration, review, and implementation of capacity-building plans for NGOs and

networks and the revision of tools (elaborated in 2006) for the management and mobilization of funds

14. Support in collaboration with JSI/Measure Evaluation and CDC/RetroCI/SI, MLS/DPPSE and

MSHP/DIPE, in developing strategies (data collection tools, KAP survey) to track behavior change among

SW frequenting HVP clinics to better understand if BCC and other prevention interventions are having an

impact;

15. Conduct a baseline assessment of HIV prevalence among a representative sample of 500 SW visiting

new service sites in FY08

16. Conduct an assessment of the HIV prevalence among 600 SW coming for the first time to the 25

different prevention and care sites;

17. Support the participation of local partners at regional conferences in order to facilitate exchanges of

lessons learned and promising practices.

3 Oct 08:

The USG team intends to support this activity, a study by Family Health International on condom use and

STIs among sex workers, at the level originally proposed in the COP08 ($254,621). This change reverses

the effect of a reprogramming action in April 2008 that had reduced the funding level by $200,000.

Title: Consistent Condom Use and STI/HIV Prevalence Among Sex Workers Attending Project Clinics in

Cote d'Ivoire

Time and money summary:

This eight-month study will cost $254,621.

Local Principal Investigators:

Bea Vuylsteke, Charles Zouzoua, Mathurin Dodo, Michel Guella, Virginie Ettiègne-Traore, Alexandre Ekra,

Marie Laga

Project Description:

The PAPO-HV project goal is to reduce HIV/STI prevalence rates in highly vulnerable populations (HVP) in

Cote d'Ivoire by: expanding the reach and increasing the quality of HVP services; building technical and

management capacity of NGOs and associations to provide services; and increasing coordination among

NGOs and other associations. PAPO-HV will expand services over 5 years. In Phase 1 (Year 1), service

delivery at three existing sites for transactional sex workers was supported. In Phase 2 (Years 2-5), the

project will establish additional service delivery sites, expanding the geographical reach of interventions and

increasing the capacity of local NGOs to provide services.

Evaluation Question:

Key program performance targets of PAPO-HV are to foster a 15% increase in condom use and a 50%

decrease of ulcerative and non-ulcerative sexually transmitted infections (STIs) among the target population

for the life of the project. Population-based surveys one of the best ways to obtain this information.

However, conducting a nationwide survey among sex workers in Côte d'Ivoire is not feasible at this moment

given the political and social instabilities. For this reason, we propose to conduct a survey among sex

workers who seek services at specialized PAPO-HV clinics. Previous studies at one sex worker clinic in

Abidjan, Clinique de Confiance, demonstrated the efficacy of a similar intervention by monitoring behaviour

and STI/HIV prevalence among female sex workers attending the clinic for the first time .

The aim of the proposed survey is to measure consistent condom use and STI/HIV prevalence among sex

workers attending the different service delivery locations supported by the PAPO-HV project.

Methodology:

A baseline survey will be conducted among a representative sample of sex workers attending seven (7)

new PAPO-HV service delivery centers selected in 2007.

The same methodology will be used for all surveys. Sex workers attending the center for the first time as

well as routine clients will be invited to participate in the survey. Informed consent will be obtained from the

participants, and a face-to-face interview will be conducted by a research assistant using a short

standardized questionnaire. The questionnaire will include questions about socio-demographic

characteristics, number of sex partners and condom use. Participants will then be invited to provide a saliva

sample and self-administer a vaginal swab (women) or provide a urine sample (men). A medical check-up

including a genital examination will be offered to participants. The completed questionnaires and samples

will be collected anonymously but linked using a numbering system, so that test results can be linked with

the results of the questionnaires. HIV testing on the saliva sample will be done at the local laboratory using

the OraQuick HIV-1/2 Rapid HIV-1/2 Antibody Test (Orasure Technologies). The vaginal and urine samples

will be shipped to the laboratory of microbiology at the Institute of Tropical Medicine (ITM), Antwerp,

Belgium, where PCR testing will be done for N. gonorrhoeae, C.trachomatis (Amplicor, Roche) and

T.vaginalis (in-house).

In addition to the evaluation survey methods described above, counseling on safe sex methods will be

provided to all participants and they will also be offered routine STI services and HIV counseling and

testing. Free treatment for STI will be provided according to routine clinical STI algorithms. A trained

counsellor of the clinic will perform the pre-test counselling on an individual basis insisting on the benefits of

doing a HIV test. The HIV test and post-test counselling will be done according normal clinic procedures.

The results will be given to the patient during the post-test counselling, but are not linked with the forms of

the evaluation survey.

Population of Interest:

Female sex workers who attend the clinics will be invited to participate in the survey.

To demonstrate a significant increase of 15% condom use and 50% decrease in STI prevalence between

data collected at baseline and the end of the project survey, the sample size should be sufficiently large.

The formula for comparing the minimum sample size for two proportions has been used to calculate a

minimum sample size per center.

The sample size will be 210 female sex workers per center.

We expected the prevalence of consistent condom use in the baseline to be 70%. We aim to show a

significant increase in condom use (15% to 85%) at end of project. Using the formula, we calculate that the

sample size should be at least 210 participants in both the baseline and the evaluation survey at the end of

the project.

We expected STI prevalence in the baseline to be 30%. We aim to show a significant decrease in STI

prevalence (30% to 15%) at end of project. Using the formula, the sample size should be at least 208

participants in both surveys.

Activity Narrative:

Budget Justification:

The budget proposed will support the implementation of the baseline evaluation survey at seven new PAPO

-HV centers which are operational in 2008. The data collection part of the survey will last an estimated 3

months.

The budget for human resources needed to carry out the survey is $38,115, which covers allowances for:

? 1 Field Coordinator

? 7 Physicians

? 14 Research Assistants

? 7 Laboratory Assistants

? 1 Data Entry Clerk

Participants will not be remunerated for transport cost or time, as the evaluation will take place during

normal consultation hours with clients from the clinic. Moreover, the procedure per client will not take more

than 30 minutes. Participants will receive extra free male condoms as incentives.

Training and supervision of the research staff will cost an additional $9,112, including travel costs.

Operational costs amount to a total of US$ 11,473 and include questionnaires, stationary, urine containers,

condoms and the cost of transporting the samples from the centers to the reference laboratory where

samples will be kept at -20°.

International shipping of the urine and vaginal samples to ITM in Belgium will cost US $31,991.

The budget for STI and HIV testing (PCR tests for N.gonorrhoeae and C.trachomatis, PCR for T.vaginalis,

HIV Elisa tests), including tests, laboratory disposables, manpower, is a total of US$ 63,869.

Human resources$ 38,115

Training and supervision$ 9,112

Operational costs$ 11,473

International Shipping$ 12,464

STI and HIV testing$ 163,930

TOTAL BUDGET$ 254,621

Primary Expected Outcome:

The rigorous evaluation study described in this document is needed to: measure the outcome of the

interventions supported by PAPO-HV; estimate the potential impact of targeted interventions; and provide

evidence-based information to help mobilize an increased response to HIV and inform future adjustments to

intervention strategies. The proposed evaluation which is part of a more comprehensive Monitoring and

Evaluation plan is designed to accomplish these tasks as well as simultaneously respond to CDC and

PEPFAR information needs.

Performance targets for key program elements include a 15% increase in condom use and a 50% decrease

of STI prevalence among the target population for the life of the PAPO-HV project. This survey will provide

the baseline data needed for evaluating the behavioral changes encouraged by the 3 current health centers

supported by the PHV project.

Following outcome indicators will be obtained and stratified by center and by type of client (first visit or

routine visit):

• Consistent condom use with clients during last working day

• Consistent condom use with boyfriends during the last week

• Condom use during last sexual act

• Prevalence of HIV

• Prevalence of N. gonorrhoeae

• Prevalence of C. trachomatis

• Prevalence of T.vaginalis

• Prevalence of genital ulcerations

Title: Estimation of the Size of Sex Worker Populations

Project Description:

The PAPO-HV project goal is to reduce HIV/STI prevalence rates in highly vulnerable populations (HVP) in

Cote d'Ivoire by: expanding the reach and increasing the quality of HVP services; building technical and

management capacity of NGOs and associations to provide services; and increasing coordination among

NGOs and other associations. PAPO-HV will expand services over five years. In Phase 1 (Year 1), service

delivery at three existing sites for transactional sex workers was supported. In Phase 2 (Years 2-5), the

project will establish additional service delivery sites, expanding the geographical reach of interventions and

increasing the capacity of local NGOs to provide services.

Money summary:

The budget for this study is $58,850.

Local Co-Investigators:

Lazare Sika, Mathurin Dodo, Charles Zouzoua, Solange Koné, Marie Laga, Ivan Yorot, Solange Koné,

Camille Anoma.

Evaluation Question:

Performance targets for key program elements include a 15% increase in condom use and a 50% decrease

of STI prevalence among the target population, and coverage of 50% and 75%, in and out of Abidjan

respectively. In order to measure coverage as an outcome indicator of the project, the denominator should

be known, i.e. the size of the target population. The proposed study aims to assess the sex worker

population size in at least five of the project sites in Côte d'Ivoire.

Methodology:

The very nature of sex work ("hidden" population) means that there are difficulties in applying the social

survey methodology to obtain information on the prevalence of sex work. Therefore, alternative methods are

needed, such as capture-recapture, which has been successfully implemented in different countries,

including Madagascar, Bangladesh, Vietnam and Ireland. [6-8].

The study method will be the same in the five sites and consists in each site of the following 2 study

components in chronological order:

A. Mapping and census

B. Capture-recapture method

First, a research team will conduct a mapping of locations where FSW can be found (where they find their

clients) and estimating the numbers of FSW who usually work at these locations. The exact locations will be

marked with the help of Glocal Positioning Software (GPS) and a small information form of the location will

be filled in, including type of the site (lodging, hotel, etc), time of the day/week/month that is most busy

time . In bars and hotels they will contact the manager/bar owner and explain the purpose of the survey.

They will ask for his assistance to get in touch with the leader of the sex workers operating in that place. If

the location is a lodging place or an area where several women work, they will identify the leader with

assistance of the peer health educator and make contact with her. GPS data will be transferred on a digital

map using Arc View software program.

The team will apply the capture-recapture method (CR method). Brochure. A few days later, in the same

places and at the same time, a second sample is "re-captured", which comprises of a certain number of SW

who were captured in the first round. Under the assumption that the proportion of marked persons found in

the second round (R/C) is a reasonable estimate of the marked proportion in the unknown population, an

estimate of the size of the entire population (N) can be made using the following formula:

M*C

N = ------

R

The study will have a total duration of one (1) month for mapping, capture and recapture per site.

Population of Interest:

Female sex workers and places where they can be found.

No sample size was calculated because all sex workers found at the sites during capture and recapture will

be approached.

Budget Justification:

The budget proposed will support the implementation of mapping, capture and recapture at 5 PAPO-HV

sites which are operational in 2008.

The budget for human resources needed to carry out the survey is US$ 13,550 which covers allowances

for:

? 1 Field Coordinator

? 2 Research assistants

? 60 Field assistants (12 per site)

? 1 Data Entry Clerk

Participants will not be remunerated, as participation only involves answering 2 or 3 questions. Participants

will receive extra free male condoms as incentives.

Training and supervision of the research staff will cost an additional US$ 21,100, including travel costs.

Operational costs amount to a total of US$ 24,200 and include capture and recapture leaflets, and other

stationary.

Human resources$ 13,550

Activity Narrative: Training and supervision$ 21,100

Operational costs$ 24,200

TOTAL BUDGET$ 58,850

Primary Expected Outcome:

It is expected that this estimate is more accurate than the estimate obtained from the mapping and census

exercise, as it takes into account mobility of sex workers and short term variations in the size of the FSW

population.

Reliable estimates of the size of sex worker populations are needed mainly for programming reasons,

including guiding the selection of new sites for expanding the project geographically and calculating

coverage obtained during and at the end of the programme. The results of this study however, will also be

used by the Ministry of AIDS of Côte d'Ivoire for policy reasons.

FHI has two main roles in PEPFAR Cote d'Ivoire's palliative care (PC) program:

1. Implementing partner of PC interventions targeting sex workers (SW) and other highly vulnerable

populations (HVP).

2. Technical-assistance provider to the Ministry of Health's National HIV/AIDS Care and Treatment Program

(PNPEC) and other partners to improve access to and quality of PC services.

Highly Vulnerable Populations:

Through its PAPO-HV project, FHI and its partners support the strengthening and expansion of services

targeting SW and their partners at 14 sites in Abidjan, San Pedro, Gagnoa, Yamoussoukro, Guiglo, Bouaké,

and seven other sites to be selected in FY07. Activities in FY07 include training of 40 PC service providers

and delivering care for 3,500 SW and their partners.

In FY2008, FHI will build on current programs with technical and financial support through sub-grants to

NGOs managing the 14 PAPO-HV implementing sites and will expand to two new sites. Technical support

to new partners will include training and supportive supervision for the implementation of a minimum

package of services. In all, direct care will be provided for 11,500 PLWHA. Additional funding leveraged

from the Belgian Development Cooperation will support operational research and evaluation of scale-up

activities.

PAPO-HV will collaborate with Alliance CI to strengthen the NGOs Espace Confiance and APROSAM in

managing mobile PC services, and with EGPAF to train health-care providers in ART. FHI will conduct

research to measure condom use and STI prevalence and to evaluate techniques for SW size estimation.

PAPO-HV will remain abreast of advances in PC service delivery for highly vulnerable groups, including

collaboration with the Institute of Tropical Medicine (ITM) to share experiences and learn from

achievements in similar programs implemented in Kenya and the DRC.

More specifically, in FY08, FHI will:

1. Continue technical and financial support to the 14 existing HVP health centers implementing PC

activities, including screening and treatment for STIs, primary health care, and prevention and treatment of

opportunistic infections. In addition, FHI will continue to support HIV support groups at all sites to provide

psychosocial support and adherence counseling.

2. Provide technical assistance in the implementation of the PC minimum package of services for HVP, in

line with MOH/PNPEC guidelines.

3. Support selection of two new sites for the implementation of PC services for SW, in collaboration with the

MOH/PNPEC and other partners.

4. In collaboration with Alliance CI, continue to provide technical assistance for the implementation of mobile

PC services for hard-to-reach SW in Abidjan and San Pedro.

5. Continue to strengthen the operational management of NGOs, including administrative and financial

management, budgeting, leadership, M&E, and mobilization of resources. FHI will continue to support the

elaboration of a quality assurance system (QAS), started in 2006 in collaboration with PEPFAR and other

partners (PNPEC, PSI, JHPIEGO). The QAS will become part of the current program management system.

In 2008, FHI will train health staff and M&E focal points at the two new sites in the use of these QAS tools.

Quality evaluation activities will be performed periodically at the existing 14 sites according to national

guidelines.

6. Continue support (started in 2006) for Espace Confiance as a national and regional training center for

health-care providers for SW, including revision of its training plan.

7. Improve coordination by providing technical assistance to national working groups, particularly the STI

Technical Working Group (GTT/IST) and the Sex Work and HIV/AIDS working group within the Ministry of

the Fight Against AIDS (MLS).

8. Conduct a baseline assessment of STIs among a representative sample of SW visiting new HVP service

sites in FY08.

9. Support revision of PAPO-HV's extension plan. This plan was elaborated in 2006, in collaboration with all

key partners, and includes geographical extension to zones previously under control of the non-government

New Forces as well as broadening of the target population to include those who engage in transactional

sex.

10. Support annual evaluation of a sustainability plan. PAPO-HV is guided by a sustainability strategy aimed

at reaching the goals of the project while preparing local partners to assume organizational and technical

management gradually over the life of the project. The annual evaluation of that plan (by all key partners)

aims at measuring progress made toward ensuring that interventions can continue at the end of the funding

period.

Technical Assistance to the MOH and Other PEPFAR Partners:

FHI provides technical assistance to strengthen assessment, quality, delivery, and coordination of PC

services by the MOH/PNPEC and other PEPFAR partners (MLS, National OVC Program, Alliance CI,

ACONDA, ANADER, PSI, CARE, EGPAF, Hope WW, RIP+, and COSCI) in accordance with the national

PC policy and the 2006-2010 national PC strategic plan. With FY07 funds, FHI is supporting advocacy

activities and reinforcing service providers' capacities. FHI is supporting the establishment of a national pool

of 44 trainers in PC and the training of 200 PC service providers. FHI is also supporting direct PC services

for at least 10,000 people in FY07 at 40 existing sites (the San Pedro pilot site, the PC sites in the seven

IRIS model departments, the 12 social center OVC platforms, and the 14 HVP health centers) and 20

additional sites (seven new HVP health centers, two departments implementing the IRIS model, and six

departments with new OVC platforms).

With FYO8 funds, FHI will continue to collaborate with other PEPFAR partners to achieve broader access to

Activity Narrative: PC services through advocacy, capacity building for service providers and community workers, and

collaboration among PEPFAR partners to harmonize and improve the quality of PC interventions. FHI will

support the extension of services by introducing PC into the package of services offered to outpatients,

including symptomatic pain relief; evaluation of social, psychological, and spiritual needs; and elaboration of

a reference system based on a family-centered approach. Extension of PC services to new sites will include

training for health-care providers.

In FY08, FHI will:

1. Continue its technical assistance to the national PC technical working group, in collaboration with Hope

Worldwide Cote d'Ivoire and its twinning with the African PC Association (APCA) and other partners

(ACONDA/ANADER, PSI, Alliance CI, CARE International), to conduct sensitization sessions for

stakeholders and to disseminate PC policy documents in 10 newly selected regions, to promote integration

of PC services in the national health system.

2. Provide support to the MOH/PNPEC and MLS to extend implementation of PC services in 20 new sites

(approximately 200 PC service-delivery facilities, including 14 HVP health centers, 12 OVC platforms, and

seven IRIS sites).

3. Continue to strengthen the collaborative framework among partners supporting or implementing PC. This

collaboration includes updating of a standardized PC and home-based care kit and a dissemination plan for

policy, norms, and procedures documents, including palliative and home-based care guides developed in

FY06 and FY07.

4. Assist the MOH, in collaboration with JHPIEGO, to integrate PC into pre-service curricula (UFR/SM,

INFAS, INFS, and Centre Technique Féminin) and continuing-education programs. FHI will also support

efforts of other partners to integrate OVC assessment and care into pre-service and continuing-education

curricula.

5. Improve the quality of PC services by developing a dissemination plan for quality assurance tools and PC

guides and by training 25 PC trainers, 100 PC service providers, 25 M&E focal points, and 25 QA focal

points. In collaboration with PC partners and CODINORM, FHI will support the implementation by the MOH

and MLS of a PC accreditation system as part of a PC quality assurance system.

6. Support the MOH and MLS, in collaboration with RIP+ and COSCI, to revise and update the community-

based care regulation framework developed in 2007 in order to define the status of community-based care

providers.

7. Support the MOH/PNPEC, MLS, and the PNOEV in revising the PC extension plan developed in 2006.

8. Assist national agencies in developing a sustainability plan and advocating with local governments and

international institutions (World Bank, Global Fund, UNDP, UNICEF, ILO, and bilateral cooperation

agencies) in order to engage their support for the national PC process, including support for access to

essential drugs.

FHI 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, FHI will

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

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

formerly supported through Alliance national Contre le SIDA.

Family Health International provides technical assistance to the National OVC Program (PNOEV) of the

Ministry of the Family, Women, and Social Affairs (MFFAS) and other ministries and PEPFAR partners to

support development, evaluation, implementation, and extension of OVC care and palliative care services.

FHI works to build the technical and organizational capacities of the PNOEV and of a national OVC

technical group (CEROS-EV) and supports the elaboration of policies, norms, and procedures for the care

of PLWHA and OVC as well as the strengthening of the national monitoring and evaluation system.

In FY07, FHI continues to support the MFFAS and other ministries (AIDS, Health) to strengthen and

improve national and local responses to the needs of OVC and other people affected or infected by

HIV/AIDS. Based on the results of an evaluation of a PEPFAR-supported district-based model of linked,

coordinated comprehensive health and social services built around the regional hospital (the IRIS model in

San Pedro), FHI is supporting the replication of this model in two departments (Abengourou and

Yamoussoukro), in collaboration with PEPFAR partners (Alliance, ANADER, CARE International, Hope

Worldwide, the Ministry of Education, JSI/Measure) and non-PEPFAR partners (UNICEF, the World Food

Program, ILO, UNFPA, UNDP, UNAIDS, World Bank).

FHI also supports the extension to six new departments, including three sites in the North and West (Man,

Bouaké, and Korhogo), of OVC "platforms," a coordination and collaboration mechanism for OVC care

partners with a social center model as the hub, along with the development of a strategy of support groups

established through the community mobilization of local associations facilitating the identification and

referral of OVC for care and support. The new social center model aims to integrate OVC-related issues

and PLWHA care and support in the range of activities implemented by social workers. The main objective

of these models is to better organize the provision of comprehensive care to people infected and affected by

HIV/AIDS, including OVC.

In collaboration with JHPIEGO, FHI continues to provide technical assistance (started in FY06) for the

integration of OVC curricula in courses of the social workers training institute (INFS). FHI helped establish a

continuing-education program for community and social workers. FHI also supported the elaboration and

dissemination of the 2006-2010 OVC National Strategic Plan while continuing organizational and

managerial capacity development of PNOEV and CEROS.

In FY07, within the IRIS model referral network, FHI supported the training of 250 local OVC care providers

who provided care and support (including palliative care) to 2,500 PLWHA and OVC.

In FY08, FHI will continue to provide technical assistance to ministries (AIDS, Health, Education, Social

Affairs) and other partners supporting or implementing OVC care in accordance with the 2006-2010

National Strategic Plan. FHI will continue to support the three IRIS model sites and the 12 OVC platforms

surrounding social centers while extending the IRIS model to four newly selected areas and implementing

OVC platforms and support groups in 12 more departments (for a total of 24 platforms based on the new

social center model and seven IRIS model sites nationwide by March 2009).

To boost preparations for scaling up OVC services, FHI will hire an international consultant to continue

technical assistance to the PNOEV begun with FY07 plus-up funds. The consultant will help the PNOEV to

develop and carry out a national strategic implementation plan that includes:

• Mapping of OVC services and partners

• Strategic placement of partners and services

• Linkages with the three primary venues for identifying OVC: health facilities, the community, and

institutions (schools, social centers, orphanages, etc.)

• Standardized tools and criteria, based on existing international tools and criteria, for assessment and

capacity building of local implementing partners, including criteria for graduation to PEPFAR subpartner and

partner status

• Coordination among all PEPFAR partners to accomplish these tasks

• Coordination of implementation of the Child Status Index tool, including its integration into the national

M&E system

• Development of a national M&E tracking system with decentralized data entry points and simpler forms for

local partner use

• Development of a specific timeline for continuing implementation and reinforcement of the national

implementation plan

In FY08, FHI will also:

- Continue to conduct a situation analysis on OVC in new platform sites, in preparation for the

implementation of the national strategy through the platform mechanism

- Contribute to improving the quality of OVC services by supporting the training of 40 trainers, 210 local

actors (community-based and social workers, rural animators, and staff at vocational and household training

centers for women and girls) in OVC care, palliative care, behavior-change communication, and social

mobilization at the 12 newly identified platform sites.

- At the social workers training institute, FHI in collaboration with JHPIEGO will support PNOEV efforts to

facilitate the piloting of the continuing education on OVC care and support. With the assistance of

JHU/CCP, the Ministry of AIDS, and other partners, FHI will participate in the development of new

messages and communication materials on OVC issues, to be disseminated throughout the country.

- In order to improve OVC legal rights, FHI will contribute to the establishment of OVC legal rights

committees and to capacity strengthening for their members to support implementation of interventions at

the 12 OVC platforms. FHI will also help to develop a functional plan for the OVC platforms with clear

guidance on how they can help their members provide better care and support for OVC.

- In collaboration with other PEPFAR partners, FHI will assist the MFFAS/PNOEV and Ministry of AIDS in

the review and updating (if necessary) of their decentralization/extension plans for OVC care and support

Activity Narrative: and the IRIS model (including palliative care). FHI will facilitate the development of indicators measuring the

contribution of each partner to implementation of the IRIS model and its OVC and palliative care

components.

- Continue to reinforce the national M&E system, in collaboration with Measure Evaluation/JSI and the

ministries of AIDS and Health, through the review and updating of OVC and IRIS indicators and data

collection tools. FHI will support the tracking of OVC data collected at social centers and other OVC

identification points (CT and PMTCT sites, TB treatment sites, PLWHA organizations, etc.). FHI will use

REPMASCI (network of journalists and artists) and JHU/CCP channels to disseminate best practices and

lessons learned from the implementation of the different models of care and coordination (IRIS, new social

center/collaboration platform).

- In collaboration with ministries (AIDS, Health, Education, Social Affairs) and other partners, provide

assistance for the review and updating of the respective national sustainability plan for OVC, IRIS and

palliative care.

- In collaboration with ministries and other stakeholders, develop and help implement a referral system for

HIV/AIDS care services, including OVC care and palliative care.

Through its PAPO-HV project for highly vulnerable populations (HVP), FHI and its partners are

strengthening and expanding HIV counseling and testing (CT) services targeting commercial sex workers

and their partners at 14 sites in Abidjan (two sites), San Pedro, Gagnoa, Yamoussoukro, Guiglo, Bouaké,

and seven other sites to be selected in 2007. In collaboration with Alliance CI, FHI is also helping the NGOs

Espace Confiance and APROSAM extend the coverage of CT services for sex workers through the use of

mobile units.

Voluntary counseling and testing is part of the minimum package of health services offered to female and

male sex workers, their partners, and other HVP clients as outpatients at 14 PAPO-HV centers. In FY07, at

least 7,500 people (including 5,500 sex workers) are expected to be tested and to receive their test results

at the project's 14 sites.

With FY08 funds, FHI will continue to provide sub-grants and technical assistance to the 14 implementing

NGOs/sites. FHI will expand PAPO-HV to two new communities through strategically selected sub-partners.

Technical support provided by FHI and its partners (the Institute of Tropical Medicine and Espace

Confiance) will include training of new service providers, dissemination and training in the use of

standardized quality assurance and M&E tools, regular participatory program reviews, and supportive

supervision in the implementation of a minimum package of services, which includes behavior change

communication aimed at HIV prevention through peer education as well as CT, STI management, palliative

care, and ARV treatment. Espace Confiance will continue to provide practical training sessions and

coaching for health-care providers in HIV prevention, care, and treatment.

Although project sites use rapid testing with same-day delivery of results, some clients prefer to leave,

saying they will come back for their results. Since FHI started this program in 2004, 38,674 HVP (65% of the

targeted population) have visited HVP clinic sites where they have been counseled, but only 18,258 (47% of

those counseled) have been tested and have received their test results. FHI will work, in consultation with

the USG team, to increase these low rates through routine CT, use of a simplified rapid-test algorithm when

it becomes available, and creative strategies for outreach and effective, client-oriented counseling.

With regard to mobile CT, FHI will continue to support two CT vans provided by Alliance CI in March 2007

to Espace Confiance and APROSAM to serve hard-to-reach HVP in remote areas, respectively, of Abidjan

and San Pedro. By the end of FY07, the mobile units are expected to produce a 30% increase from FY06 in

the total number of HVP counseled and tested with receipt of results by project-supported CT services.

Based on innovative CT approaches it began using in 2007, including routine CT for all patients visiting

HVP health centers and a family-based approach, FHI expects to increase the number of people it counsels

and tests in FY08 to at least 20,000.

The PAPO-HV project will establish links with EGPAF for the training of the project's CT counselors and lab

technicians.

Additional funding from the Belgian Development Cooperation will support operational research and scale

up evaluation activities in 2008. PAPO-HV will conduct baseline studies of condom use and STI prevalence

among sex workers in FY07 at seven sites and will use capture-recapture techniques to estimate the size of

the sex-worker population in at least five cities where HVP activities for sex workers are undertaken.

At the regional level, PAPO-HV will collaborate with the Institute of Tropical Medicine to exchange

information about project experiences in Cote d'Ivoire, Kenya, and the Democratic Republic of Congo.

Specifically, FHI will use FY08 funds to:

1. Continue technical support to the 14 CT service-delivery sites supported in 2007.

2. Use new data on the size of the sex-worker population to increase CT service coverage by strengthening

existing sites and expanding services to new sites selected according to pre-established criteria and in

collaboration with the Ministry of AIDS (MLS), the National HIV/AIDS Care and Treatment Program

(PNPEC), and other partners. At the selected sites, FHI will support CT activities through sub-grants to two

NGOs, in replication of an intervention model for HVP/sex workers based on the successful Clinique de

Confiance.

3. In collaboration with Alliance-CI, provide technical assistance for the integration of mobile CT services in

the package of services aimed at difficult-to-reach sex workers in Abidjan (with NGO Espace Confiance)

and San Pedro (with NGO APROSAM) in order to expand geographic coverage and improve access to

services.

4. Strengthen support for promotion of CT services for HVP during outreach activities by 165 peer health

educators and community workers and during health education and prevention activities at 14 clinic sites.

5. Train peer health educators and community workers on the simplified CT algorithm expected to be

adopted. FHI will work with the PEPFAR country team to determine the feasibility and pace of outreach CT.

6. Continue support to 14 NGOs/sites in support of innovative CT strategies for HVP, including couples and

family counseling and positive-prevention activities.

7. Support the MLS and the Ministry of Health, in collaboration with key partners (PSI, Alliance, RIP+), to

develop and implement innovative prevention and care strategies for men who have sex with men.

8. Continue to support the elaboration of the quality assurance system (QAS) started in 2006, in

collaboration with other partners (PNPEC, PSI, JHPIEGO, RETRO-CI) in order to better evaluate the quality

of health-care services. The QAS will be part of the current program management system. In 2008, FHI will

train health staff and M&E focal points at its two new sites in the use of these QAS tools before providing

the tools to them. FHI will also support the training of community-based providers in CT and DBS

techniques for QA. In addition, FHI will continue standardization of CT practices at existing sites through

dissemination of standardized tools elaborated at the national level, under the supervision of the PNPEC.

Activity Narrative: Quality evaluation activities will be performed periodically at the 14 existing sites according to national

guidelines in order to improve quality of CT services.

9. Continue support to Espace Confiance, in collaboration with JHPIEGO, EGPAF, RETRO-CI, and the

regional AWARE project, to create a national and regional training center at Clinique de Confiance for

health-care providers working in settings dedicated to the prevention and care of STI/HIV among sex

workers. FHI will support the revision and adaptation of the CT training plan (adopted in 2006) for future

needs of this training center. In line with its capacity-building plan and the PAPO-HV sustainability plan,

Espace Confiance will assume greater responsibilities for implementing activities for sex workers within

PAPO-HV prevention and care centers, in preparation for its future responsibilities with the training center.

10. Continue to strengthen the internal and external referral systems for PLWHA to appropriate services,

including care and support groups, ART, palliative care, and OVC services. FHI will provide this technical

assistance in areas using the departmental comprehensive-care model (IRIS) as well as areas using the

district-approach model, with direct involvement of the district chief medical doctor in supervising and

reporting activities in both models.

11. Conduct a baseline assessment of HIV prevalence among a representative sample of 500 sex workers

visiting new service sites in FY08.

12. Continue to address stigma and sexual violence by providing HVP-friendly services delivered by staff

with nonjudgmental attitudes and by conducting BCC activities with 16,000 other HVP (partners, clients, bar

owners).

13. Support revision, after evaluation, of the extension plan of Project PAPO-HV. This plan was elaborated

in 2006, in collaboration with key partners, and includes geographical extension to zones formerly under

control of the nongovernmental New Forces as well as extension of the target population to occasional sex

workers. A revised plan will allow reorienting interventions, including primary health services for HIV-

infected people, and expanding them in the whole country.

14. Continue to support annual evaluation of a plan for sustainability of project activities. PAPO-HV is

guided by a comprehensive sustainability strategy aimed at reaching project goals while preparing local

partners to gradually assume organizational and technical management. The annual evaluation of that plan

(by all key partners) will help FHI monitor its progress and adapt its plan to ensure the continuation of

activities at the end of donor support.

Support the participation of local partners at regional conferences in order to facilitate exchanges of lessons

learned and promising practices.