The overall goal is to expand access to comprehensive HIV/AIDS care and treatment while building capacity and contributing to sustainable service delivery within the health sector of the three northeastern regions of Côte dIvoire to attain targets detailed in the national strategic plan.New objectives for COP 12 are:Expand and integrate HIV care and ART in 19 new public health facilities in 3 regions, totaling 61 sites; and to expand and integrate confidential C&T in 52 new public health facilities in 3 regions, totaling 130 sites,Expand and integrate PMTCT in 50 new public health facilities in 3 regions, totaling 121 sitesPlease see below for strategies in different programmatic areas. In addition, HAI will support quarterly supervision of care and treatment activities to ensure quality of services, data, and effective management of ECD teams.A comprehensive M&E plan will be assured at all levels using national HIS and will be led by a high-level M&E advisor based in Bouake and technical M&E backstop from HQ. HAI will use OR and implementation science to address system bottlenecks and weaknesses. 5-10% of each programmatic areas budget will be allocated to M&E activities.5- Vehicles:Through COP11: 1New requests in COP12: 4Total planned vehicles for life of mechanism: 10New request justification:2 in the Savanes, 1 in Bouaké, and 1 in Abidjan. HAI anticipates taking on 29 new health sites in Savanes previously funded by EGPAF with over 6274 registered PLWHA and 3697 on treatment (EGPAF data, March 2011). 16 sites in Ferké will require intense support in the first year. The Abidjan office needs a vehicle to participate in national strategic meetings.

HAI will strengthen linkages between program sites with non-HIV services by:Strengthen service linkages between all entry points (PMTCT, TB, CT, ARV, Family planning, and Community testing) to HIV careCollaborate with community counselors and local NGOs to strengthen linkage between maternal/child health and family planning and adult care services, to facilitate patients tested HIV positive to be registered in care

Collaborate with FANTA, PATH and PNN to integrate nutritional assessment for HIV patients.In collaboration with PAM, support distribution of food supplements and follow up care of 300 malnourished HIV patientsFacilitate wide distribution of nutrition assessment tools and facilitate data collection.Strategies for incorporating WASH include:Integrated in all counseling session in antenatal consultation, sensitization message on importance of hand washing, training, support and sensitization on hygiene for traditional birth attendants.Broadcast in different languages sensitization message on importance of hand washing.Support the transport for the distribution of water purification kits, mosquito nets and condoms from the PSP to districts and equally from districts to health facilitiesHAI will build capacity bySupport creation and ongoing meetings of multidisciplinary adherence clubs at each health facility to monitor patients adherence to careSupport timely feedback of information to health facility and district staffHAI will support all regions and districts which are listed above, whose population is approximately 1,855,953, of whom 92,798 are expected to be pregnant women.

The types of HIV care and support services HAI will implement include:Facilitate initial CD4 analysis of at least 95% of patients tested HIV positive and who are registered into care.Strengthen Cotrimoxazole administration in HIV care and adequate capture of this information.Support 15 local NGOs to offer palliative care for PLHA and linking of community care with hospital based careHAI will use the following strategies to improve the quality of service delivery:Support situational analysis by district management team for 52 new sites earmarked for integration of adult HIV care and support services.Support peer counselors through local NGOs to track patients on care to improve clinical and laboratory follow upIdentify best practices and organizing forums to share best practicesInitiate and support health facility level analysis of monthly activity data for adult care and support indicators and use analysis of the results to influence decision making and improve quality of care.HAI will address client retention and referrals by:Strengthen systematic registration of all HIV positive into care from all the points of entry.Strengthen follow up CD4 counts based on national protocol for patients not on ARV.Strengthen positive prevention activities for PLWHA in health facilities, in support group meetings. This will contribute to maintaining contact these patients not on ARV in care and ensure adequate follow upFacilitate and finance monthly adherence meetings at each health facility. These meetings will help track patients follow up, early identification of defaulters (CD4 follow up, Cotrimoxazole pick up, clinical appointment, etc) and set up measure to actively search for defaulters

HAI will support all 3 where 92,798 are expected to be pregnant women. The total number of pregnant women attending at least the first ANC visit is approximately 74,238.The goals are to support the national strategic plans activities in providing care and support to OVC who are identified in HAI-supported sites or from the community and linking them to appropriate care, support and treatment services as needed. HAI implements nationally accepted standards of care for programming related to OVC.The strategies HAI will use include:Support 6 NGOs to offer care and support to OVC and the families and linkages with health facilities. NGOs selection will be based on their OVC and grant management experience, and sole PEPFAR source of financing for same activity. They will receive HAI support and coaching to ensure a continuum of care for families caring for OVC. HAI will collaborate with EGPAF and other PEPFAR partners to ensure coordination of NGO financing. The Social center will be implicated in all process of selection and subcontracting a partner.Collaborate and support (activities coordination) of Social centers activities in Bouaké, Beoumi, Korhogo, Ferke, Bouna and Bondoukou, the OEV platforms and facilitate community care workers participation in activities of social center and OEV platform.Support monthly meetings of youth clubs, including themes of abstinence as appropriateSupport participation of health facility staff in meetings of Social centers and OVC platformSupport strategies to support integration of female OVC into community including supporting schooling and vocational trainingEncourage birth reporting to the civil status of all HIV-exposed children in the first three months of life with the support of NGOs and social centersTo measure the success of the program, HAI will:Facilitate and strengthen data aggregation and analysis at district level, in collaboration with the Social center.Continue to use the software CSI (developed by PNOEV) to track OVC through the system and measure progress.

Strategies for improving the quality of service delivery include:Support and implement quality services to OVC and their families in accordance with the priorities of PNOEV and PEPFAR for COP12 and according to the needs of these OVC and their families in collaboration with URCRegular coaching visits to NGOs, community centers and community health workers by HAI staff

Strategies for strengthening links with MCH services include:Strengthen referral of OVC to health facilities for medical care.Integration of OVC activities in ANC clinics, post natal clinics, external pediatric consultation services, vaccination and nutrition services.Activities to contribute to food and nutritional support include:Collaborate with PNN, FANTA and PATH to integrate nutritional assessment at OVC service centers and for children identified in the community.Support local NGOs to identify and refer malnourished children identified at community level to health facilities for nutritional treatment, care and support.WASH activities: Integrating information of water treatment in counseling and proper storage of water during home visits.

HAI will support all regions and districts which are listed above, whose population is approximately 1,855,953. HAI clinical staff, including the National Director, Clinical Director, and regional Clinical Advisors, will lead the implementation of TB/HIV activities.

HAI plans to implement the following strategies:Evaluate non-CDT/CAT health facilities that offer HIV and TB treatment to measure their effectiveness in TB treatment in HIV treatment sitesSupport integration of complete package of care for TB/HIV patients (HIV testing, TB screening, Cotrimoxazole, condom use, STDs, CD4, ARV, TB treatment) at 12 CDTs/CATs (including 5 new sites) and 10 ARV sites.Conduct regular quality control measures in TB/HIV sitesProvide office & laboratory supplies to TB service outlets in collaboration with PNLTCoordinate joint supervision of TB/HIV activities by PNLT/PNPEC/DistrictsSupport distribution of TB screening tools/ IEC materials in PMTCT and HIV treatment sitesSupport reorganization and equipping TB and ARV sites for infection control (including the distribution of national guidelines, awareness, decongestion, and ventilation of waiting areas)Support integration of active search and TB screening and treatment in PMTCT and HIV sitesSupport training of nurses and TSLs in ARV sites on preparation of sputum for TB diagnosisSupport transport of prepared sputum slides for suspected TB patients in ARV sites for diagnosis at 9 TB sites.Support PNLT in training community health workers on observance, reference and counter reference between TB & HIV centers and community linkagesSupport transport of samples to Abidjan for MDR-TB testing for patients with recurrent TB infection and treatment failure.Support HAI Technical officer for TB/HIV and TB/HIV counselors.Support activities to strengthen TB care and treatment in children under 5 years?Reproduce and distribute screening tools for children in TB and HIV sites?Reproduce and distribute algorithms for TB diagnosis in children at TB and HIV sites

Alignment with Country Policy: HAI is able to show that activities are aligned with the country policy and strategic plans for TB and HIV. HAI participates in national strategic planning and policy meetings, and there is a Liaison officer in Abidjan who is in constant contact with all relevant ministries. In addition, HAI consults with national ministries before implementing programs. Finally, as mentioned above, the MOHA is implicated in all activities that HAI implements in its sites.

Monitoring and Evaluation: Whenever possible, HAI uses the national health information system to monitor and track trends over time and jointly analyzes these data with health managers to improve the quality of services. In addition, HAI plans to conduct evaluations as well as use operations research during the COP12 year in order to assess progress, identify weaknesses or bottlenecks, and develop solutions with our MOHA counterparts.

Capacity Building: HAI plans the following activities:Support training of 18 doctors and nurses in ARV sites on preparation of sputum for TB diagnosisCoordinate joint supervision of TB/HIV activities by PNLT/PNPEC/DistrictsSupport PNLT in training of 60 community health workers on observance, reference and counter reference between TB & HIV centers and community linkages

HAI will support all regions and districts which are listed above, whose population is approximately 1,855,953, of whom 92,798 are expected to be pregnant women. HAI will contribute to pediatric treatment scale up by:Support coaching of providers and implementation of PCIME to reinforce pediatric care and support in health facilities and community.Encourage doctors to coach and follow up all facility personnel on the importance of pediatric care and support for HIV-exposed infants,Strengthen systematic registration of all children tested HIV positive (PCR testing and rapid testing) into care from all entry points (including post natal and FP clinics)Strengthen regular follow up CD4 counts for children not on ARV.Strengthen Cotrimoxazole administration from 6 weeks age for all children born to HIV positive women and those not eligible for ARV.Facilitate transport of PCR samples from all regions to AbidjanCoordinate and support regular visits by district managers to monitor pediatric HIV careStrengthening already existing HIV positive clubs in all health facilities and creation of new positive clubs in new health facilities to provide psychosocial support to HIV positive children and their familiesSupport creation and ongoing operation of monthly multidisciplinary adherence clubs at each health facility to monitor patients follow up in pediatric careActivities that support the needs of adolescents with HIV: Support and encourage infected young men to adopt AB methods during routine care in health centersActivities that promote integration with routine pediatric care include:Strengthen linkage to pediatric care from all entry points; PMTCT, pediatric out patients, pediatric in patient , pediatric emergencies, pediatric treatment, vaccination services, nutrition services, delivery room and family planning services.Support community counselors (through local NGOs) to work and link all the pediatric entry points, identify children born to HIV positive women at entry points and referral to pediatric HIV care services.Support and strengthen PITC at all entry points: pediatric outpatients, inpatient, pediatric emergencies, and vaccination and nutrition services.Strategies to strengthen links with other programs (MCH, FP) include:Strengthen counseling for best breastfeeding practices for children of HIV positive mothers by HAI staff and districts focal point during the coaching in health facilitiesStrengthen active search of infants of HIV + women at vaccination, nutrition, post natal clinics and family planning clinics.Nutrition activities include:Collaboration with PNN, and PATH to train providers and integrate nutritional assessment and follow up of children at post natal clinics, family planning clinics, vaccination services (PECNAP).Collaborate with PNN and other partners to support the provision of food supplement (plumpy nuts, fortified milk etc.) and therapeutic nutrients for 100 malnourished children.Support local NGOs to identify and refer malnourished children identified at community level to health facilities for nutritional treatment, care and support.WASH activities:Integrating water treatment information in counseling and proper water storageCapacity building activities include:Support quality improvement methods in collaboration with URC and JHPIEGO.Support data analysis at health facility level to improve quality of care.Best practices sharing activities.

HAI will build structural and operational capacity of health districts, in close collaboration with regional health boards, to further develop skills of the health workforce and improve the quality of service delivery. HAI will take a systematic approach to health systems strengthening (HSS), addressing six essential areas of the health system framework as recommended by the WHO.

Human Resources (HR): Interventions will focus on building capacity of district health management teams (DHMTs) and training them to conduct periodic site assessments. This activity will be progressively integrated into the routine supervision process. The building of DHMT capacity will also involve the creation of budgeted work plans, supervision, data management, and quality of care. Ariel will strengthen HR of regional and district health boards, as well as the integration of social workers, to ensure, maintain, and sustain community activities at sites.

Service Delivery: HAI will implement a basic package of care integrating clinical and community activities. Quality improvement (QI) activities will be incorporated into district and regional work plans. Joint supervision led by HAI and DHMTs to ensure the progressive transfer of skills will take into account quality of care and data and will emphasize the feedback process through periodic QI follow-up meetings and a written report. HAI will provide TA to health care workers through regular site visits and systematic integration of a district focal point into the joint supervision team to facilitate progressive transfer of skills. Tools and procedures will be developed for that purpose.

Leadership & Good Governance: HAI will emphasize improving functionality of health regional teams and DHMTs to ensure good coordination of interventions through statutory meetings and those related to quarterly, semiannual, and annual follow-up of performance. HAI will advocate for the adoption and integration of several available tools into the national process quality of care and capacity assessment.

Health System Financing: HAI will build the capacity of national partners at the local level and will train them on resource mobilization and on the efficient use of funds for health service delivery.

Health Information System-Improving data collection: HAI will build capacity of sites and districts to produce quality data through training sessions on the use of new tools, provision of computers, data management software, and internet connectivity in district and regional epidemiological surveillance centers.-Data quality improvement: HAI will provide support to district and regional health boards when they implement data management procedures and will conduct routine data quality assessments with integrated improvement plans. This activity will be progressively integrated into the routine process of supervision.-Data use & analysis: HAI will support districts and regions in data analysis and use for decision making at the local level. Data validation meetings, follow-up on performance, and reports will ensure dissemination of data.

Technology: HAI will deploy data management software at districts and sites. HAI will facilitate the use of the PIMA CD4 test in labs to improve access to CD4 counts, reaching even remote sites. Lab activity supervision will be conducted by the QI staff of each region.

HAI will support all regions and districts listed above, whose population is approximately 1,855,953. The estimated prevalence of this region according to the 2005 EIS is 3.41%, and about 17% of people seeking services at health sites in the regions are counseled and tested for HIV.

HAIs approaches include:Support integrated implementation of Testing and Counseling (T&C) services including PITC and family approach at all service points (PMTCT, inpatient, outpatient services, TB, family planning services, and pediatric follow up) in 130 sites including 52 new facilities in collaboration with district team/PNPECImplementation of pilot project with Projet San Francisco for couple C&T and follow up of discordant couples in 10 pilot health facilitiesOrganize T&C coaching visits by district HIV focal point in collaboration with HAI T&C focal point and PNPEC to monitor the quality of counseling sessions, techniques of testing and data quality controlSupport implementation of internal quality control for rapid test at all T&C sitesSupport local NGOs in community sensitization with community and religious leaders to promote positive change in male norms, roles, and behaviors.Support local NGOs to reduce loss to follow up, reach out to those tested HIV+ and link them to appropriate health servicesAddress HIV vulnerabilities among young girls and women in all services in health facilities.Assist MSLS in activities for National HIV Testing day in the three regions.Targets and results for the last year can be found attached in the attached Excel file.

HIV Testing and Counseling links with other programs:Support implementation and strengthening PICT at pMTCT, inpatient, outpatient services, TB, family planning services in facilities and support reference and counter-reference between sitesCoordination of T&C activities in health facilities with district pharmacies to avoid stockouts of suppliesTo link with PWP programs, HAI will support the reproduction of IEC materials (videos, posters, etc) from JHU and distribution to health facilities.

Testing Algorithm: HAI uses the national HIV testing algorithm and plans to support logistics for distribution of nationally approved algorithms for PICT.

Activities to strengthen referral system and patient tracking system:Provision of peer counselors and community counselors (through local NGOs) at all PICT points to reinforce reference system to HIV care and treatment services.Strengthen tracking of patients tested HIV negative and implement retesting at all service entry pointsReach out to male partners on gender based violence and stigmatization and linking family members to follow- up HIV services. Special focus will be placed on following up sero-discordant couples and ensuring access to careData quality assurance of individual level care and support databaseData audit once a year to avoid duplication in counting PLWHA including care and support and PWP activities

Activities to monitor and measure effective linkages:Conduct operations research on effectiveness of linkages between programs, evaluation of lost to follow up, factors associated and develop strategies to reduce such losses

HAI will support regions and districts listed above, whose population is approximately 1,855,953, of whom 92,798 are expected to be pregnant women. The total number of pregnant women attending at least the first ANC visit is approximately 74,238:To scale up quality PMTCT services, HAI will:Support expansion of pMTCT to 50 new facilities, including 13 public and 3 private sites were previously part of a PBF system and will need extra technical and logistic support to restart or reinforce activities.Support joint situational analysis for new sites with the district management teams & PNPEC.Support integration of complete pMTCT package in ANC (C&T, CD4, ARV prophylaxis, nutrition), primary prevention and prevention of unintended pregnancies among women of reproductive age.Promote exchange of experience and best practices between PMTCT facilitiesPackage ARV prophylactic kits for HIV positive pregnant women (intra partum and post partum ARV doses).Support the reproduction, diffusion, and utilization of the new health booklet for pregnant women and their infants.To promote demand creation, HAI will:Promote competition between sites of the same district or region with certificates of participation and the provision of equipment and materials for the high performersUse results from qualitative studies identifying bottlenecks to access of care and access to CD4 countsTo reduce lost to follow up, HAI will:Regularly analyze follow up registers available onsite with health workers, social workers, and community based organizations to link HIV+ women to health facilities, CD4 analysis, and other servicesProvide psychosocial support if the woman decides to disclose her status to her partner and provide emotional support and encouragement for partner testing (collaboration with Engender Health)Work with local NGOs to support home visits by peer counselors to HIV+ pregnant women to improve follow up and maintain them in PMTCT.To support integrated PMTCT, HAI will:Integrate HIV C&T in family planning services.Strengthen diagnosis & treatment of STDs at ANCEstablish a collaborative framework with PNSR to strengthen integration of reproductive health in PMTCT.Plans to decrease unit cost per patient and improve program efficiencies, HAI will:Use results from OR activities to identify bottlenecks, propose solutions, and measure the result of the change.Collaborate with PAM, FANTA, PATH, UNICEF, PNN, and local NGOs to integrate nutritional assessment of pregnant women and children at ANC at post natal clinics, family planning clinics, and vaccination services.Support the provision of food supplement for malnourished pregnant women and children and strengthen evaluation activities in collaboration with UNICEF and PNN.To build capacity of health care providers and facilities, HAI will:Support bi-weekly coaching visits to facilities by HAI pMTCT assistants in collaboration with the district HIV focal point.In collaboration with chief medical officers, elaborate pMTCT micro and overall district operation plansSupport PNPEC in organizing 3 regional trainings of midwives on prevention using national integrated modules (at least 20 participants per session).To build supervisory, data collection, and monitoring capacities, HAI will:Support regular quarterly district supervision visits to health facilities.Support district level data collection agents.

HAI will support all regions and districts which are listed above, whose population is approximately 1,855,953.HAIs onsite supervision includes onsite coaching. This takes lessons learned in a formal training environment and applies them to onsite activities to troubleshoot bottlenecks in the actual implementation. This is followed by several months of joint MOH-HAI supportive supervision.Over 50% of sites HAI supports do not have a permanent doctor on site and require extra technical, financial, and logistical support. To assure the effective administration of treatment, HAI organizes a system of roaming doctors, who visit treatment sites twice a month to prescribe treatment, perform follow up check ups, and diagnose any opportunistic infections.HAI anticipates 19 new adult treatment sites in COP12. These sites were previously funded under a PBFS which has ended. HAI will provide extra technical and logistic support to these sites during the transition.

HAI tracks and evaluates clinical outcomes by:Collaborate with URC and JHPIEGO to implement QI methods in all 19 new health facilities, to improve overall quality of care.Regular monitoring to improve data quality.Initiate and support facility level analysis of monthly data and share of analysis with MOH to influence decision making, improve quality of service, and provide longitudinal tracking of epidemic.Collaboration with DPM to conduct pharmaco-surveillance and monitor frequency of undesirable side effects of treatment.Organize monthly prescribers meeting to discuss and address cases of treatment failure, blood samples transportation and ensure feedback of resultsSupport installation of SIGDEP in 10 new health facilities in collaboration with DIPE.Data and quality of care audit once a yearHAI supports improved retention of patients initiated on ART by:Support strategies for infection control at ARV sites such as decongestion, ventilation and lightening of waiting areas and active search for TB.Support the PSP in data collection and compilation at site and district level for drug and lab supplies.Make available and functional EDT in hospitals in collaboration with SCMSParticipation in preparatory meetings for quantification of ARVs and laboratory products and in the TWG of the Monitoring Committee of ARVsSupport to health districts in delivering monthly ARV reports, commodities and attrition summary reportsCoaching health providers and managers for the delivery of ARVs to patients by the HAI staffSupport community counselors and local NGOs in coordinating psychosocial support groups, home visits, and follow up visits for PLWHA and their partners to ensure retention in care.HAIs strengthens links with MCH and FP services by:Support peer counselors (through local NGOs) to coordinate referral between MCH and FP services to care and treatment servicesNutrition activitiesSupport food supplements distribution to 571 malnourished HIV patientsCollaborate with FANTA, PATH and PNN to integrate nutritional assessment for HIV patients.Ensure procurement, and distribution of adult weighing scales in health facilities.Facilitate distribution of assessment tools and facilitate data collectionWASH activities:Support distribution of water purifiers to 200 HIV positive adult families and training on treatment and proper storage of drinking water.sensitization messages on importance of hand washing.

HAI will support all 3 regions where 92,798 are expected to be pregnant women. Activities that contribute to pediatric treatment include:Support pediatric HIV treatment in 19 new health facilities in three regions, totaling 61 HAI supported sites that provide pediatric treatment.Provide technical and financial assistance to 3 health centers of Savanes region that were previously supported by EGPAF funds.Make available and functional EDT (a pharmacy software) in general hospitals in collaboration with SCMSSupport and strengthen strategies to ensure that all eligible HIV positive children are rapidly evaluated and started on HAART as appropriateCollaborate with URC and JHPEIGO to implement quality improvement tools in all 19 pediatric treatment facilities to improve quality of services.Initiate and support health facility level analysis of monthly activity data for adult care and support indicators and use of analysis result to influence decision making and improve quality of service.Support to health districts in delivering monthly ARV repports, commodities and inclusion attrition summary through the flow of blood samples to the reference laboratory of the districtCoaching managers for the delivery of ARVs to patients by the HAI staffConduct data audit once during the yearImproved communication between Health district and health facilities across the conveying of blood samples developed by HAICollaboration in the process of quantification of ARVs and laboratory products.Support to the PSP to collect data at the health district, general hospitals and CHR for the quantification of ARVs and laboratory products.Activities to support adherence, improve retention, and establish linkages to reduce loss to follow up include:Provide coaching to all providers on counseling and analysis of health booklets to strengthen identification and active search of infants of HIV positive women at post natal clinics, vaccination, nutrition services, and pediatric outpatient consultation and inpatient pediatric ward.Support creation and ongoing operation of multidisciplinary support and adherence clubs at each health facility to provide psychosocial support and monitor patients adherence to treatmentSupport peer counselors to follow up HIV-positive women and their children in the community and to link them to health facilities, including home visits and follow up to ensure attendance at medical visitsActivities to promote integration of pediatric HIV treatment in MCH, nutrition, and community based activities include:Collaborate with PNN and PATH to integrate nutritional assessment for children at post natal clinics/ family planning clinics, and vaccination services.Support local NGOs to identify and refer malnourished children identified at community level to health facilities for nutritional treatment, care and support.Activities to provide specific services to adolescents include:Support and encourage infected young men to adopt AB methods during routine services at health sites.Activities to provide early infant diagnostic services, PITC, and CD4 availability include:Support logistics and transport of PCR samples from all 3 regions to reference laboratory in Abidjan and results back to health facilitiesSupport transport of CD4 samples for all HIV positive children to the reference laboratorysupport integration of PCR and pediatric rapid HIV testing at post natal clinics & PF clinics