Sixty percent of Cote d'Ivoire's population is rural, much of it functionally illiterate and underserved by health and other services. Since late 2005, the USG has funded the Ivoirian National Agency for Rural Development (ANADER) to extend access to HIV/AIDS prevention, care, and treatment services to rural areas. Working through its development agents, village action committees, and volunteer community counselors, ANADER and its subpartners have provided behavior change communication (reaching 123,097 people with AB and 231,917 people with Other Prevention outreach in FY 2009), mobile and fixed-site HIV testing and counseling (29,652 in FY 2009), and care and support for people living with HIV/AIDS (3,065) and orphans and vulnerable children (10,029), with linkages to medical care and treatment, support groups, economic strengthening activities, and other services, in 146 villages in five regions. With a no-cost extension, ANADER's award will end in September 2010.

Results achieved and lessons learned suggest that a) extending HIV/AIDS prevention and care services to rural areas through village action committees can produce impressive results and break pervasive stigma, and b) with foreseeable resources, this model cannot be scaled up beyond selected higher-prevalence and/or high-impact zones.

For the next five-year period, the USG team has launched a competitive FOA designed to build on ANADER's work and to focus on:

- Behavior change communication (BCC) reaching national coverage in rural areas, with an emphasis on targeting and involving the most vulnerable populations, including girls and young women and out-of-school youth.

- Broader HIV testing and care interventions in selected higher-prevalence and/or high-impact zones

- Integration of all supported HIV/AIDS activities into existing (non-HIV) structures and activities, with capacity building to enable and sustain local ownership.

A TBD partner will be funded in the HVAB, HVOP, HVCT, HBHC, and HKID budget codes to engage involvement of the community (e.g. local health or water committees, traditional and religious leaders, teachers, health care providers, women's and youth associations, etc.) and to build local capacity to implement and monitor evidence-based, culturally appropriate, gender-sensitive HIV prevention interventions. The partner will oversee targeted, coordinated mass-media (including local radio) and proximity BCC activities reaching rural areas in all regions of Côte d'Ivoire (over five years) to promote HIV testing; prevention of mother-to-child transmission (PMTCT); risk awareness; risk reduction through abstinence, fidelity, and, for populations engaged in high-risk behaviors, correct and consistent condom use; reduction of stigma and discrimination; reduction of gender inequity; and use of care and treatment services through a strong referral network.

In addition, in selected zones, the partner will build on and refine ANADER's more comprehensive model of providing HIV/AIDS prevention, testing, and care, including OVC care, through local structures. Details will be worked out with the awardee and national stakeholders, but use and strengthening of local capacity will be a priority. Project-specific quantifiable milestones to measure indigenous capacity-building and progress toward sustainability will include increasing the number and improving the quality of locally organized and supported HIV/AIDS activities, as well as demonstrating quantifiable progress through the implementation of a sustainability plan. The partner will participate in relevant national technical, coordination, and quality-assurance committees and progressively reinforce the capacity of faith- and community-based organizations and village and district structures to promote quality, local ownership, accountability, and sustainability of activities.

The partner will work to link project interventions with existing HIV care and treatment and other social services in the area, including services supported by other PEPFAR-funded initiatives and by other donors (Global Fund, World Bank), and will promote coordination at all levels, including through bodies such as district, regional, and national HIV coordination committees and networks of PLWHA and faith-based organizations.

Monitoring and evaluation (M&E) of all interventions, including baseline and impact assessments, will be essential in measuring the success of these activities. Using participatory approaches, the partner will develop and implement a project-specific strategic information/M&E plan consistent with national policies and OGAC guidance that draws on available data and national tools and uses quantitative and qualitative methods. This plan will require the collection, analysis, and dissemination of data to ensure adequate baseline data and regular data reports to support targeted service delivery, program M&E, and appropriate information systems. This information will also serve to measure coverage and reach of mass media messaging and to analyze intervention effectiveness.

The partner will contribute to the key issues of gender equity and increasing women's access to income and productive resources by, among other things, using gender-sensitive materials and approaches in HIV prevention outreach; targeting girls and women as priority groups for HIV prevention, care and support, and economic strengthening activities; and by promoting HIV services (including PMTCT services) to women.

In selected higher-prevalence and/or high-impact zones, the TBD partner will

build on ANADER's model of providing HIV/AIDS prevention, testing, and care, including OVC care, through existing local structures. Details will be worked out with the awardee and national stakeholders, but use and strengthening of national and local capacity will be a priority.

In Adult Care and Support, the partner will work to support:

- Improved referral networks, follow-up, and care and support for people living with HIV/AIDS (PLWHA) and their families, including support for status disclosure, testing for their sexual partners and children, home-based palliative care, Prevention with Positives activities (cotrimoxazole, impregnated bed nets prioritizing pregnant women and children under age 5, nutrition assessment and counseling, food support in cases of malnutrition, TB screening, hygiene education, condoms, treatment adherence counseling, etc.), support groups, and active, prominent roles for PLWHA in program planning and implementation.

- Use of situational analyses and validated, evidence-based approaches to develop appropriate economic strengthening and nutritional support for eligible PLWHA and OVC families, such as food-production income-generating activities, vocational training, savings and loan groups, etc.

- Provision of home-based care and support for PLWHA, including kits, psychosocial support, and referral to health centers, social services, and OVC care

Training of community counselors in psychosocial support and support group therapy for PLWHA and OVC

Training of religious leaders in psycho-spiritual support for PLWHA and HIV-affected people

Production and distribution of media materials (print materials such as posters brochures, and mass media outlets such as radio spots) with messages designed to reduce stigma and discrimination against PLWHA and OVC

The partner is expected to provide at least 2,500 PLWHA by September 2011 (5,000 by Year 5) with care, support, and PwP services, including HIV testing promotion for household members, and to ensure that these clients receive cotrimoxazole (at least 80% by Year 5), TB screening (100%), and ART adherence counseling (90%) and have access to bed nets and a safe water supply (75% by Year 5). At least 500 PLWHA are expected to receive food and/or nutrition services over five years, and all intervention villages are expected to have active PLWHA support groups.

In selected higher-prevalence and/or high-impact zones, the TBD partner will

build on ANADER's model of providing HIV/AIDS prevention, testing, and care, including OVC care, through existing local structures. Details will be worked out with the awardee and national stakeholders, but use and strengthening of national and local capacity will be a priority.

In the OVC technical area, the partner will work to support:

Identification of OVC and assessment of their needs in accordance with PEPFAR guidance and national directives

Care and support for OVC as needed, including health care, educational, legal, and psychosocial support, follow-up, provision of items such as impregnated bed nets, nutrition assessment and counseling, food support in cases of malnutrition, TB screening, and hygiene education

Based on situational analyses and using validated, evidence-based approaches, appropriate economic strengthening and nutritional support for eligible PLWHA and OVC families, such as food-production income-generating activities, vocational training, savings and loan groups, etc.

At least 15,000 OVC are expected to benefit from care and support by Year 5, including 8,000 by September 2011.

In selected higher-prevalence and/or high-impact zones, the TBD partner will

build on ANADER's model of providing HIV/AIDS prevention, testing, and care, including OVC care, through existing local structures. Details will be worked out with the awardee and national stakeholders, but use and strengthening of national and local capacity will be a priority.

The partner will work to support mobile, facility-based, and home-based HIV testing and counseling reaching at least 150,000 people over five years, including 12,000 by September 2011. Expanded uptake of confidential TC will emphasize promotion of routine testing at health-care facilities, in partnership with health-care providers, as well as follow-up (e.g. home-based) testing for sexual partners and children of people living with HIV/AIDS, and improved access to testing for other populations (e.g. through mobile testing).

The partner will work to support training of health workers and community counselors (at least 1,000 over five years) in TC using the new national testing algorithm and finger-prick technique; on-site coaching and supervision of community counselors and health workers providing TC services; referrals to care and treatment for patients testing positive and their families, including OVC; and mass-media and proximity campaigns promoting TC.

The TBD partner will oversee targeted, coordinated mass-media (including local radio) and proximity HIV prevention behavior change communication (BCC) activities conducted through local structures and reaching rural areas in all regions of Côte d'Ivoire over five years. Engaging and building on involvement of the community (e.g. local health or water committees, traditional and religious leaders, teachers, health care providers, women's and youth associations, etc.), the partner will work to build local capacity to implement and monitor evidence-based, culturally appropriate, gender-sensitive HIV prevention interventions. In the technical area budget code of AB prevention, these interventions will promote risk awareness and risk reduction through abstinence and fidelity, delay of sexual debut, reduction of multiple partnerships, reduction of transactional and intergenerational sex, reduction of stigma and discrimination, reduction of gender inequity, as well as use of HIV testing and prevention of mother-to-child transmission (PMTCT) services, with referral to appropriate care and support services.

While details remain to be planned with the eventual awardee and national stakeholders and targets will depend on the timing of the award and funds availability, approaches are likely to include implementation of a national communications strategy for rural areas promoting the coordinated use of rural radio stations (50 broadcast events per village per year) and networks, listening groups, and other community-based activities involving key spokespeople (such as health-care providers, teachers, and religious, traditional, youth, and male/female community leaders) for HIV prevention education. The partner will identify and implement targeted BCC tools and strategies in collaboration with other PEPFAR partners, with priority target groups including girls, women, and out-of-school youth. Individual and small-group interventions focused on HIV prevention through AB are expected to reach at least 548,500 individuals over five years, including 80,000 by September 2011.

Promotion of PMTCT services will be a key element of HIV prevention messages; over five years, individual and small-group interventions are expected to reach at least 54,850 women with PMTCT messages, including referral of pregnant women to TC services with appropriate linkages and follow-up for those who test HIV-positive.

The partner is also expected to train 500 community counselors per year (2,500 over five years) in HIV prevention interventions; to collaborate with a national network of religious leaders (ARSIP) to strengthen religious leaders' capacities to address HIV/AIDS in their communities; to work with women's organizations to help women discuss AB-related issues with their children; and to identify, pilot, and evaluate other innovative, evidence-based HIV prevention activities involving HIV prevention and reproductive-health education, risk awareness, life skills, leadership development, and vulnerability reduction for at-risk subpopulations, including out-of-school youth, with a particular focus on girls.

The TBD partner will oversee targeted, coordinated mass-media (including local radio) and proximity HIV prevention behavior change communication (BCC) activities conducted through local structures and reaching rural areas in all regions of Côte d'Ivoire over five years. Engaging and building on involvement of the community (e.g. local health or water committees, traditional and religious leaders, teachers, health care providers, women's and youth associations, etc.), the partner will work to build local capacity to implement and monitor evidence-based, culturally appropriate, gender-sensitive HIV prevention interventions. In the technical area budget code of Condoms and Other Prevention, these interventions will promote risk awareness and risk reduction through correct and consistent condom use, in conjunction with abstinence, fidelity, reduction of multiple partnerships, and reduction of transactional and intergenerational sex, as well as use of HIV testing and prevention of mother-to-child transmission (PMTCT) services, with referral to appropriate care and support services.

While details remain to be planned with the eventual awardee and national stakeholders and targets will depend on the timing of the award and funds availability, approaches are likely to include implementation of a national communications strategy for rural areas promoting the coordinated use of rural radio stations (50 broadcast events per village per year) and networks, listening groups, and other community-based activities involving key spokespeople (such as health-care providers, teachers, and religious, traditional, youth, and male/female community leaders) for HIV prevention education. The partner will identify and implement targeted BCC tools and strategies in collaboration with other PEPFAR partners, with priority target groups including sex workers, girls, women, and out-of-school youth. Individual and small-group interventions focused on HIV prevention through an ABC approach are expected to reach at least 548,500 individuals over five years, including 190,000 by September 2011.

The partner will support community outreach activities promoting condom use and other HIV prevention methods through mass campaigns and theatrical presentations as well as individual and small-group approaches; support procurement and distribution (including social marketing) of male condoms to rural communities to accompany prevention messaging and encourage correct and consistent condom use; and support development of a package of prevention activities targeting people living with HIV/AIDS, in collaboration with national and local PLWHA organizations.

Promotion of PMTCT services will be a key element of HIV prevention messages; over five years, individual and small-group interventions are expected to reach at least 54,850 women with PMTCT messages, including referral of pregnant women to TC services with appropriate linkages and follow-up for those who test HIV-positive.

The partner is also expected to train 500 community counselors per year (2,500 over five years) in HIV prevention interventions; to collaborate with a national network of religious leaders (ARSIP) to strengthen religious leaders' capacities to address HIV/AIDS in their communities; to work with women's organizations to help women discuss AB-related issues with their children; and to identify, pilot, and evaluate other innovative, evidence-based HIV prevention activities involving HIV prevention and reproductive-health education, risk awareness, life skills, leadership development, and vulnerability reduction for at-risk subpopulations, including out-of-school youth, with a particular focus on girls.