Columbia University is being funded under the new CDC TA mechanism to support a PHE in PMTCT, along

with other PHEs in HTXS and Counseling and Testing.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $6,384,683

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Background

The 2005 AIDS Indicator Survey (AIS) has provided important information about the HIV/AIDS epidemic in Cote d'Ivoire,

permitting better targeting of prevention and care efforts. Within an adult HIV prevalence of 4.7%, females in all age groups were

far more likely than males to be infected (6.4% vs. 2.9%). HIV prevalence showed a steep increase in women ages 20-34, from

0.4% below age 20 to 14.9% among ages 30-34. Male prevalence may be mitigated by near-universal (96%) circumcision.

Geographic differences included marginally higher HIV prevalence in urban settings and marked regional differences, from 1.7%

in the Northwest to 5.5% in the South and East and 6.1% in Abidjan.

Sexual debut was reported by age 15 for 23% of females and 10% of males, by age 18 for 71% of females and 48% of males.

The population aged 15-49 reported that 5% of females and 31% of males had two or more sexual partners in the previous year;

and 66% of females and 48% of males did not use condoms with non-regular sex partners. While only 2% of men reported paying

for sex, 31% of unmarried women ages 15-19 reported having a sex partner who was at least 10 years older. One-third of married

women were in polygamous marriages.

HIV knowledge was low, especially among women who had no education, lived in rural areas, or lived in the North/West.

Conversely, both high-risk behavior and condom use were more likely among better-educated, urban people who lived outside the

North/West. Attitudes reflecting intolerance conducive to HIV stigma and discrimination were widespread, particularly among

women.

FY05-08 Response

In collaboration with national and local government, the USG-CI pursues a comprehensive ABC prevention approach emphasizing

delay of sexual debut, partner reduction, stigma reduction, reduction of intergenerational relationships, and promotion of gender

equity. Individual, couple, and family HIV counseling and testing is seen as a key primary- and secondary-prevention tool, with

linkages to care and treatment and community support systems. Promotion of couples testing is intrinsically linked to promotion of

mutual faithfulness and of condom use within sero-discordant couples, as well as stigma reduction activities and activities to

promote safe disclosure and to minimize risk of violence or rejection by spouses and intimate partners. Promotion of abstinence

and fidelity among youth is complemented by condom education, risk assessment, and targeted communication for those at high

risk.

Other efforts include prevention interventions to mitigate the epidemic's impact on vulnerable subpopulations at risk of acquiring

and transmitting HIV, including the uniformed services, immigrants and displaced populations, seasonal field workers,

transportation workers, street children, and those engaging in transactional sex. In 2007 and 2008, the USG targeted specific

groups more strategically by reinforcing the roles of teachers, religious leaders, health care workers, and parents in promoting

social norms that encourage fidelity and partner reduction and address risk factors such as alcohol and drug use. With PEPFAR

support, the Ministry for the Fight Against AIDS (MLS) and JHU/CCP established a behavior change communication (BCC)

committee to improve quality, coverage, and coordination of BCC activities. A significant focus was to develop youth- and gender-

specific prevention programs emphasizing biology of transmission, interpersonal communication and other life skills, gender

equity, and prevention of gender-based violence. Emphasis was also placed on BCC capacity-building at central and

decentralized levels, with approaches that will be strengthened and harmonized in 2009.

In 2007-2008, the USG increased from 12 to 17 the number of prime partners in prevention, including three NPI partners, and

reached 633,095 people with AB outreach (including 358,511 with A-only messages) and 671,632 with OP outreach. Ten partners

have multiple sub-partnerships with local or regional Ivoirian organizations. Prime partners include two government agencies, nine

international NGOs, and five local NGOs. The U.S. Department of Defense and Department of State contributed to prevention

activities targeting military prevention, testing, and care; awareness-raising through an HIV/AIDS Road Show; and promotion of

workplace HIV prevention and wellness. Expansion of activities has been possible because of additional funding from PEPFAR

and because access to geographic zones of the country that were limited during the socio-political crisis are slowly being

reintegrated into the national public health sector. Media communications campaigns were executed, with extensive use of

regional and local radio, national television, and billboards in urban areas, plus targeted posters, videos, graphic novels, and other

printed materials that complemented trainings, peer outreach, counseling, and educational activities.

FY09 Priorities

Efforts begun in 2008 will continue to strengthen prevention program quality and coordination by determining and promoting best

practices, assuring population coverage and eliminating duplication among sub-partners, evaluating new programs for potential

comprehensive integration, strengthening capacity of sub-partners through a standardized program, integrating prevention

programs in HIV care and treatment settings, and conducting formative research to better understand prevention needs for high-

incidence populations identified in the AIS. A new partner will work with the MLS and all prevention partners to coordinate

harmonization of peer-education approaches and build capacity in measuring outcomes with the general population of youth and

adults, plus other highly vulnerable populations. Communications initiatives will better coordinate across partners to deliver

complementary local activities with gender-sensitive and age-specific strategies. Successful community parent-child

communication models will continue, the village committee model will be reinforced, sub-partners will continue to work with

displaced women and children as well as migrant populations, the pilot Families Matter program will expand to satellite sites, and

the delayed pilot of Men as Partners (MAP) will be rapidly implemented with two prime partners, their sub-partners, the Ministry of

Education, and the uniformed services to address male norms and attitudes. Gender based violence as a risk factor will be

addressed through the MAP program; better coordination and collaboration with the Ministry of Family, Women, and Social Affairs

(MFFAS), UNFPA, and UNICEF; community activities at the sub-partner level informed by ongoing International Rescue

Committee research; and training of medical professionals using national modules.

In FY08, PEPFAR contributed to defining core competencies and clarifying roles of lay counselors in health facilities and

communities. With FY09 funding, the USG will support treatment and PMTCT partners to provide training and compensation for

lay counselors dedicated to providing prevention interventions for all clients, as well as "prevention for positives" and effective

referral to community-based care and support for HIV-positive clients and their children. This intervention will link facility-based

services with comprehensive follow-up care and strengthen the continuum of services to reach more people infected and affected

by HIV/AIDS. It will also engage ministries to recruit and assign social workers and medical professionals to under-served areas.

The program will continue to build on the success of targeted prevention campaigns and efforts to integrate prevention and life-

skills messages and activities into sustainable systems. With a flatlined budget and a strong focus on quality and accurate

counting, targets for FY09 are lowered for numbers of people reached with prevention messages (800,000 in AB, 676,000 in OP).

PEPFAR-supported interventions will reinforce capacity of responsible ministries and decentralized leadership to conduct strategic

planning, prevention activity management, and measuring of project outcomes among teachers and students, health care

professionals, and uniformed services and their families. Prime and sub-partners will continue to implement targeted interventions

for truckers, displaced and mobile populations, professional and transactional sex workers and their clients, sexually active in- and

out-of-school youth, and health- and education-sector workers. For transactional sex workers and truckers, the USG continues to

support services (including clinics with peer outreach) that provide support, CT, condom-negotiation skills, and STI management,

as well as links to health and HIV care, treatment, and social and legal services. These complement and are coordinated with EU

and World Bank regional projects targeting transport routes.

Cote d'Ivoire has an extensive brothel- and bar-based sex-worker population, which has been targeted by prevention services

from FHI sub-partners for more than a decade. Program coverage expanded in 2007-08. In FY09, nascent sites will be

strengthened, satellite rather than large new sites will be actualized, and population-size estimates will continue using a protocol

approved in 2008. PEPFAR will continue to coordinate with UNFPA and the World Bank for coverage and will actively participate

in the national MARP working group to harmonize minimum packages of services and service mapping for commercial and

transactional sex workers. Research activities begun in 2008 will continue to document risk factors for women engaging in

transactional sex, and findings of formative research on men who have sex with men (MSM) will be used in creating targeted

communications campaign and services for MSM beginning in Abidjan and expanding to other urban sites.

FY09 priorities in prevention of sexual transmission will include:

1. Continuation and expansion of community-based interventions targeting the general population in rural and urban areas with

BCC activities, promotion of counseling and testing, and gender-sensitive communications campaigns for older youth and young

adults. This is also part of efforts to increase coordination with the Ministry of Youth, the Ministry of Technical Training, and the

MLS to address the needs of out-of-school youth based on a 2008 national youth prevention strategy.

2. Continuation of quality assurance and improvement measures, along with national mapping of community-level prevention

interventions, their proposed and actual content, and the proportion of the target population reached in partnership with the MLS

and international actors. Harmonized approaches, indicators, and expected outcomes will be collaboratively proposed and

validated, including required PEPFAR indicators. This includes a new technical partner for the Ministry of Education to improve

coordination, strategic planning, management, and technical quality of all activities and materials targeting in-school youth.

3. Completion of the pilot phase and establishment of satellite sites and partner training of trainers for evidence-based

interventions to increase parent-child communication and HIV awareness among parents and pre-adolescent children.

4. A stronger focus on coordination and collaboration with other UN organizations focused on gender and HIV will be actualized,

including efforts to address gender-based violence and female genital mutilation as risk factors. The delayed pilot of the Men as

Partners program will be implemented, evaluated, and scaled up through EngenderHealth, with rapid transfer of capacity to

multiple partners and local management.

5. A focus across program areas on capacity-building tools used by prime partners with their sub-partners, based on an analysis

in FY08. Partners will collectively develop a national standardized protocol for sub-partner capacity development, supervision,

data collection, and monitoring and evaluation, which all prime partners will then implement.

6. The PEPFAR Prevention With Positives initiative has been delayed due to the need for translation. With FY09 funding, this

initiative will be adapted in Cote d'Ivoire, and a training strategy will be rolled out by care and treatment partners and the Ministry

of Health. It will be implemented via doctors, nurses, and lay counselors in HIV care and treatment settings in both faith-based

organizations and the public sector, with an emphasis on abstinence, fidelity, partner testing, proper nutrition and hygiene,

adherence to treatment, personal coping strategies, and condom use.

7. The formative evaluation of women with recent infections has been changed to allow Cote d'Ivoire to work with the team

implementing similar research in Lesotho and Zambia. Instead of examining behaviors leading to new infections among women

ages 20-34 years, research will focus on risk and protective factors influencing the engagement of women ages 19-29 in

transactional sex. Interventions based on the results will be developed, implemented, and evaluated. This intervention is critical

considering the "feminization" of Cote d'Ivoire's HIV epidemic documented in the AIS, including the evidence of increased HIV

incidence in this group, the high proportion of young women who have sex with older men, and the prevalence of sero-discordant

couples in which the woman is infected.

8. The assessment of risk behaviors and sero-prevalence of MSM begun in 2008 will be completed in Abidjan, and specific

communications and interventions for this potential high-risk group will be developed based on early and final results. A technical

review committee has been established, and the MLS-led HVP working group is spearheading the national effort, which includes

international organizations, the Ministry of Health, and multiple implementing organizations.

Table 3.3.02:

Columbia University is being funded under the new CDC TA mechanism to support two PHEs in HTXS,

along with other PHEs in PMTCT and Counseling and Testing.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.09:

Columbia University is being funded under the new CDC TA mechanism to support two PHEs in Counseling

and Testing, along with other PHEs in PMTCT and HTXS.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 15 - HTXD ARV Drugs

Total Planned Funding for Program Budget Code: $17,929,677

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Background

The procurement of ARV drugs in Cote d'Ivoire is managed within the Ministry of Health (MOH) by the National Public Health

Pharmacy (PSP), the National Drug Regulatory Authority, and the National Public Health Laboratory (LNSP). Actual service

delivery and data systems for patients are managed by the National Care and Treatment Program (PNPEC). Principal sources of

ARV drugs are PEPFAR, Global Fund (GF), Clinton Foundation, and the MOH. All incoming commodities are delivered to the

PSP Depot for distribution to service sites. Supply-chain issues are managed by a technical committee of representatives from the

MOH, donors, implementing partners, and PLWHA that meets monthly to discuss program status and overall supply issues. This

joint platform is functioning but needs significant strengthening to achieve a well-coordinated and transparent national program.

PEPFAR technical inputs are critical to the operation of this group.

The growth of the national HIV/AIDS program in Cote d'Ivoire has been impressive, with an increase in the numbers of adults and

children on treatment over the past 24 months. The national goal is to reach 77,000 ART patients by September 2009, with

PEPFAR providing ARV drugs for 60,000 of these.

With the designation of Care International as principal recipient for Phase 2 of the GF Round 2 HIV grant, SCMS has become the

official primary technical assistance provider for supply chain management for both PEPFAR and GF programs. All drugs, lab

supplies, and other commodities are procured by SCMS for all PEPFAR implementing partners. Virtually all drugs in the Cote

d'Ivoire national ARV protocol are now approved for PEPFAR purchase by the Food and Drug Administration (FDA).

Following the MOH policy for coordinated procurements, and in an effort to improve efficiency, donors are following an approach

of integration and "complementarity" under which no single donor provides all required inputs to a given site. The interdependent

nature of the national program promotes the collaboration desired by the USG, but it also greatly increases the vulnerability of the

program. This approach requires aggressive and regular data collection from all service sites individually, as well as pro-active,

transparent information sharing among all stakeholders. Unfortunately, inconsistent implementation of this approach resulted in an

ARV overstock in FY08. To prevent a reoccurrence, a logistics management information system (LMIS) using paper-based tools

was developed and implemented at all sites, and warehouse management software was installed at the central level to improve

the traceability of ARVs and other HIV-related commodities.

FY09 Priorities

PEPFAR will continue to follow the joint procurement planning approach and will ensure that technical assistance provided by

SCMS benefits the entire national program. In coordination with the MOH, PEPFAR partners and the GF, the PEPFAR program

will concentrate on strengthening quantification, stocks management, and distribution processes at the central level and will

support PSP to expand its decentralization plan to further strengthen in-country supply-chain processes at the regional and district

levels. The PEPFAR program will also strengthen and implement ARV tracking (LMIS) systems at all levels.

In addition to procuring most HIV/AIDS-related drugs and consumables for PEPFAR Cote d'Ivoire partners, SCMS will use FY09

funds to continue strong technical and management assistance in support of the PSP's leadership and coordination role in the

national program. SCMS will be held accountable for specific performance results and will adjust its operational plan, in

consultation with the USG team, PNPEC, and the PSP, as the situation in Cote d'Ivoire evolves. SCMS will regularly update

national ARV forecasting calculations based on actual use patterns and will provide ongoing analysis of commodities consumption

compared to patient treatment data. This is critical to ensure rational commodities management and realistic scale-up planning.

SCMS will also advise the MOH and partners on current pharmaceutical market developments, USG-approved products and

suppliers, and manufacturing capacity as it affects supply to Cote d'Ivoire.

• Procurement

The PEPFAR program will procure and deliver ARVs to the PSP central warehouse and will ensure that a rational distribution plan

is predetermined for each site, based on prior consumption, and validated at least quarterly using client data and physical

inventory spot-checks. The PEPFAR program expects to be providing ART for 60,000 patients by September 2009, including

22,080 new patients. SCMS will procure enough drugs for these patients, with a five-month buffer supply at the central level.

While Cote d'Ivoire's Round 2 Global Fund HIV project will end in March 2009 and its application for a Round 8 was unsuccessful,

it is expected that the Global Fund will continue to provide ARVs for its current patients. The USG team is represented on the

CCM and in regular consultation with the GF principal recipient and is prepared to help address potential programmatic

implications of a GF service-delivery gap as well as to provide technical assistance for an expected Round 9 application.

• Commodities Forecasting

The PEPFAR program will continue to refine and improve the quality, accuracy, and frequency of ARV and other commodities

forecasting and supply planning in partnership with the GF, Clinton Foundation, UNITAID, and others through support to the PSP

Cellule ARV. SCMS will perform one 24-month ARV quantification and a one-year supply plan, including for patients needing post

-exposure prophylaxis as well as PMTCT patients. SCMS will continue to build capacity by working in collaboration with PSP staff,

Retro-CI, the National Reference Laboratory, and other PEPFAR partners to make quarterly revisions to the national supply plan

as well as to conduct regular cross-over analyses to compare commodities dispensed by the PSP and specific sites with actual

patient data to inform program management decisions. In an effort to strengthen capacity at the regional and district pharmacy

levels, SCMS will train pharmacists in forecasting and supply planning for ARVs and monitoring and evaluation methodologies.

In collaboration with the MOH and other partners, SCMS will maintain a Web-based ordering system as well as an inventory

tracking system for PEPFAR-procured HIV commodities. Authorized partners will be able to log in and view orders from SCMS,

track their delivery progress, and confirm historical data regarding their orders. The Warehouse Management System (MACS) and

its integration with LMIS software will enhance the PSP's inventory management and distribution systems. SCMS will complete

the implementation of SIMPLE-1 and SIMPLE-2 software at all facility-level and district pharmacies to track ARV dispensing data

used in stock management and forecasting efforts. These solutions, in combination, are expected to greatly enhance

transparency of commodities management and decrease stock-outs and emergency orders due to inadequate forecasting at all

levels.

• In-country Warehousing and Distribution

Following an assessment of district pharmacies in FY08, the PEPFAR program will complete an evaluation of the physical

infrastructures of the district pharmacies and make recommendations on their storage needs. PEPFAR partners will work closely

with the European Union to create an implementation plan for meeting the standard guidelines and will strengthen storage

conditions for five district pharmacies (San Pedro, Abengourou, Yamoussoukro, Bouake, and Korhogo). PEPFAR will support

capacity building within the five district pharmacy infrastructures through the purchase of equipment, training, and supervision to

ensure monthly commodities distribution to ART sites and regular quarterly updates of national forecasts and procurement

planning.

In addition, PEPFAR will support technical assistance to reinforce the PSP's capacity to assess, upgrade, and renovate its

regional warehouse to bring it into compliance with recognized standard storage conditions for ARVs, OI drugs, and other

HIV/AIDS commodities. .

• Tracking and Reporting System

SCMS will continue to ensure computerized supply-chain management systems, specifically procurement and inventory

management and distribution systems that include detailed information on ARVs, OI drugs, lab reagents, and testing materials, as

well as commodities for palliative care and OVC support. SCMS will build upon the MACS solution in FY09 by installing MACS-

LMIS software at both central and district levels. When the programs are interfaced, ARV and lab logistics data collected at the

site level will give the district and central level pharmacies actual consumption data. In addition, the WMS solution at the district

level will provide districts with the same stock management tools as the central level. Following the implementation of the WMS-

LMIS solution, pharmacists from each district will be trained in the software.

SCMS has designed a laboratory commodities tracking tool that will be implemented during the FY09 program year. In addition,

following changes to national regimens, the ARV logistics management toolkit and training-of-trainers document will be revised,

reproduced, and disseminated in FY09. SCMS tools development will strengthen the transparency and national ownership of

supply-chain responsibilities and enable the PSP to access monthly inventory and dispensing reports from each treatment site.

These reports and analyses will alert care and treatment stakeholders anytime the projected virtual stock of any ARV or HIV-

related commodity drops to less than three months at the national level or at any site. (Projected virtual stock is the sum of current

inventory and expected consumption, plus realistically expected new deliveries.) In FY09, site-level monthly report submission will

be followed up by SCMS-supported supervision visits to both intermediary and site-level treatment facilities to reinforce training

and to monitor reporting accuracy.

Table 3.3.15:

In April 2009 reprogramming, FY09 funds made available for development of a Partnership Framework are

being allocated to Columbia University to support technical assistance for task-shifting (e.g. from physicians

to nurses) to improve ART service delivery.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.18: