The goal of the project is to build a strong and sustainable response to the HIV/AIDS epidemic in selected regions of Côte dIvoire. Project objectives are to:1.Promote primary HIV prevention and improve HIV care, support, and treatment services2.Contribute to the strengthening of health systems supporting HIV/AIDS service delivery3.Build the technical and organizational capacity of selected local NGO and government partners to implement HIV prevention, care, and treatment interventions4.Transfer program support from EGPAF to local government and non-government partners, including Ariel FoundationOver the five years of Project Djidja, EGPAF will achieve the transfer of its program to Ariel Foundation for service delivery, pre-service training institutions to ensure a large cadre of highly performing and motivated health care workers are available, and finally to the MOH Regional Health Directorate. The transition of these activities and skills will result increasingly in cost efficiencies as local ownership of health care services scales up.Vehicles through COP11: 0 New requests in COP12: 1 Total planned vehicles for life of mechanism: 1 New request justification: To support supervision and mentorship of the Regional Health Departments1 vehicle ($55,000) will be used to support supervision and mentorship of the Regional Health Departments.

EGPAFs overall strategy for implementing Adult Care and Support activities under Project Djidja during COP12 will include the following components: early identification of HIV-infected persons, linkages with community and health system, increase retention into care; reduction in HIV-related mortality and morbidity; improved quality of life; and reduction of HIV transmission to uninfected persons. Target populations in coverage area of Djidja project will include HIV-positive pregnant women testing at all entry points (ANC visits, labor and delivery); men/partner and women testing positive through other counseling and testing initiatives; Through these activities, EGPAF will contribute to PEPFARs goal of supporting care for 12 million persons globally and 385,000 persons within Côte d'Ivoire affected by HIV/AIDS.

Family-centered HIV care and support services will be performed at health facilities and at community-based organizations (CBOs). These services may include:Psychosocial support to PLWHA and their families through CBOs;Prevention with positives package of services offered according to the national standards, including cotrimoxazole, condoms, insecticide-treated bednets, WASH supplies, counseling on desire for procreation, and partner disclosure; andNutritional assessment, counseling and food support, and economic strengthening activities.

Specific activities will be implemented to provide high quality and efficient care and support, such as:-Strengthening of functioning bi-directional referral systems between all HIV testing points and care and treatment services;-Involving community care givers to reach families of index subjects; and-Familiarization/training of care providers to deal with PwP.

EGPAF will continue its quality initiative through the existing site quality teams using EGPAF EZ-QI tool, while working with the MOH and PEPFAR-funded URCfor integration of quality teams and development of a national tool to include relevant indicators to be systematically measured. Quality assurance and improvement activities will then be transferred progressively to the MOH through district and regional levels, whose teams will complete mentorship visits, data quality analysis (DQA), data reviews, and be part of the supervision team at district level.

Djidjas overall retention rate of patients in care and support will be increased through improved follow-up of HIV- positive patients, including mandatory follow-up counseling sessions with trained community health workers.

The activities listed above will be supported by a strong system for monitoring and evaluation, in close collaboration with the national counterparts in division of information, planning and evaluation (DIPE), and PNPEC ). Focus areas for M&E will be:oImprovement of data collection process: roll out new harmonized national data collection;oExpansion of the national patient tracking software (SIGDEP) to non-computerized sites; andoConduct of DQAs to improve data quality.

There are an estimated 440,000 orphans due to AIDS in Côte d'Ivoire. Under Project HEART, EGPAF partnered with 12 local CBOs to offer care and support services to OVC in 129 sites. In 2010, 16,518 eligible OVC were supported through these partnerships. Project Djidjas approaches will work toward the goal of offering care and support packages in accordance with national guidelines to a maximum number of OVC through various partnerships with CBO, NGO, PNOEV, and specific PEPFAR community partners in Djidja-supported regions. This objective is consistent with the national goal of reaching 385,000 persons affected by HIV/AIDS, including OVC.

Project Keneya, an EGPAF project whose primary goal is to create a sustainable local response to HIV/AIDS through strengthened prevention and care services in northern Côte d'Ivoire, was designed as a response to the needs of OVC, with a strategy of one OVC, one intervention, assisting community counselors to ensure consistency with national guidelines and standards. Keneya and Djidja will work together for complementarity of service in Vallée du Bandama to roll out the holistic package of care and support services to OVC there. Djidja will implement the following related strategies for improving quality of life, wellbeing, and reduction of morbidity and mortality within OVC (children under 15) due to AIDS during COP12 in the remainder of its covered regions:1)Identification of OVC within community, care, and treatment settings. Specific messages related to care and support benefits for OVC will be disseminated through various communication channels and targeting community, PLWHA, health care workers (HCW), and children2)Needs assessments of identified OVC3)Ensuring access to care and support services including immunization, nutrition assessments, malaria prevention, WASH supplies, and vitamin A supplements4)Coordination of bi-directional referral systems for linkages of OVC support to spiritual, legal, educational, housing, and economic strengthening services5)Capacity building of community members, families, and HCW who are the main actors of the OVC care and support team. To ensure effective transition to local authorities, EGPAF withotherpartners will develop SOPs and job aids as part of capacity building of district staff, social centers, and CBOs.6)Continue to support national health systems strengthening through expert technical assistance to the MOH and building the capacity of networks of OVC partners.OVC care and support performance will be assessed through data quality reviews and analysis made by quality improvement (QI) teams at community and heath center level. Joint supervision of social workers and HCW will be necessary to maintain and improve quality OVC services. EGPAF will strengthen the capacity of both groups.All these activities will be supported by a strong monitoring and evaluation system that will focus on technical assistance to CBOs to strengthen their M&E systems, leading to collection of high quality data and the use of data to improve services provided to OVC. EGPAF will work jointlywith national counterparts such as PNOEV under the technical guidance of the CDC/PEPFAR team.

Côte d'Ivoire has experienced a resurgence of TB, with annual incidence increasing more than 30% between 2000 and 2009. Since TB treatment typically occurs at the 51 specialized TB centers throughout the country, the TB/HIV one stop shop approach remains challenging. Only TB centers (CATs) perform TB diagnostic tests and treat TB. At the seven major TB centers in the country, EGPAF has helped integrate HIV services, including testing and treatment, into TB services. At CAT Adjamé, 90% of TB patients (1,129) were tested for HIV in Q4 2010, and other major TB centers also have high HIV-testing rates. Concurrently, under Project Djidja EGPAF will focus efforts on improving the integration of TB screening into standard HIV services at ART sites. As of the end of June 2011, under Project HEART 36% of HIV-positive patients were screened for TB; this will be 60% by the end of Djidja first project year (PY1 ). Under COP11 funds for PY1, Djidja will initiate a new approach, using HCW at regional TB centers as champions of TB screening in HIV clinics, after having built their capacity. If this strategy is successful, EGPAF will expand it under COP12. Building on a recent, small-scale initiative under Project HEART to integrate TB treatment into services at ten ART sites, including five EGPAF-supported sites, Djidja will extend these activities to additional EGPAF-supported sites in Djidja project regions targeting current TB patients and HIV-positive patients in care or on ART.EGPAFs proposed TB/HIV activities are aligned with national policy and strategy for TB driven by the national TB program. During COP12, Djidja will enhance activities in TB centers, especially:1.-HIV screening forTB patients through scale-up of provider-initiated testing and counseling;2.-Increased access to a package of care and support services for TB/HIV patients: cotrimoxazole, PwP, palliative care, WASH, and bed nets;3.-Improved quality of care for TB/HIV patients including clinical and biological follow-up of side effects and resistance guided by the most recent national and WHO recommendations. EGPAF will participate in the process led by PNLT to develop a national strategy for infection control and provide care and treatment of multi-drug resistant cases of TB; and4.-Ensure transfer of HIV-positive patients cured of TB to ART centers to avoid new TB incidence.The continuum of care with follow-up of patients and their families in the community will improve quality of care and life. In HIV centers, screening of all HIV patients for TB must be systematic. EGPAF will contribute by building capacity of HCWs and ensuring availability of new patient medical registers and data collection tools, including the TB form to facilitate TB case finding in patients visiting HIV center sites.Project Djidja will leverage activities being implemented by other PEPFAR partners in similar technical areas and in the projects coverage area through collaboration in training of health care workers, in support to the PNLT and through the development of a joint workplan for the implementation and monitoring of TB/HIV-related activities.-TB/HIV activities under Djidja will be closely monitored and evaluated by EGPAFs Strategic Information & Evaluation (SI&E) staff. In collaboration with PNLT and PNPEC, EGPAF will: develop efficient strategies for completeness and timeliness of TB/HIV data reporting and organize joint supervision in order to ensure effective se

EGPAFs strategy for pediatric care and support activities will include early identification of HIV-infected children and the provision of a basic package of health services to include vaccinations, malaria prevention, WASH supplies, vitamin A, and nutritional status assessments, with the goal of reducing HIV-related morbidity and mortality and improving quality of life.EGPAF will work closely with CBOs and other PEPFAR partners to establish strong referral systems to capture most children in need of care, including siblings of those already enrolled in care. In Vallée du Bandama region, Djidjas facility-based pediatric care services will complement Project Keneyas mostly community-based services. In Lagunes region, EGPAF will sign an MOU with PEPFAR partners and provide small grants to CBOs (pending availability of funding ) to increase demand through community awareness campaigns in the catchment area of supported sites. Promotion and establishment of strong formal linkages between communities and health facilities will increase access and retention in care for HIV-exposed, -affected, and -infected children under 15 years, as well as adolescents ages 15-18, who are the targeted populations for pediatric care and support in the project coverage area of Lagunes and Vallée du Bandama.Family-centered HIV care and support services will be performed at all entry points (PMTCT, family planning, vaccination, and weighing units). Health facilities will reach out to families of index subject children or mothers with the involvement of the community network. Specific activities will be rolled out aiming to provide high quality and efficient care and support to improve childrens quality of life. These services may include:Expansion of comprehensive palliative care and psychosocial support (PSS) programs for children and their familiesImproved care and support services for adolescents: PSS, PwP, peer support groups, specific follow-up schedulesReferrals to care and treatment services for access to adequate care to reduce morbidity and mortalityUnder COP12, EGPAF will continue to assist districts in service delivery and work with the regional level to coordinate QA/QI efforts in the region. Quality officers at sites, districts, and regions will be included in the Continuing Medical Education program to update and increase their knowledge and thus enable them to provide onsite TA to their peers.Djidjas overall retention rate of children in care will be improved by the integration of HIV services within MCH settings, integrated follow-up of HIV mother-baby pairs, and specific HIV-positive adolescent follow-up including mandatory follow-up counseling sessions with trained CHWs and peer educators. EGPAF will strengthen its bidirectional referral system by integrating messages to families of HIV-exposed, affected, and infected children to improve quality of life, promote family centered care and support activities, and strengthened networks of care.The activities listed above will be supported by a strong system for monitoring and evaluation, in close collaboration with the national counterparts (DIPE, PNPEC). Focus areas for M&E will be:oImprovement of data collection process; roll out new harmonized national data collectionoExpansion of the national patients tracking software (SIGDEP) to non computerized sitesoCompletion of DQA to improve data quality

As part of the transition initiative launched under Project HEART, EGPAF has been striving to reinforce the Ivorian health system through various interventions, including human resources for health (HRH) through a pre-service training program, health financing through performance-based financing (PBF) mechanisms, quality initiatives, service delivery models, dissemination of validated national standards, and other initiatives. With the end of Project HEART, EGPAF will continue to strive to support the national health system under the new Project Djidja. During year one, Djidja intends to evaluate and/or document those initiatives and share lessons learned with national counterparts. If the decision is made to continue with transition to ownership by the MOH, EGPAF will provide TA and work to leverage additional resources to assist the government under COP12. Preliminary discussions held with EGPAFs HSS national partners have resulted in consensus of priorities to be addressed.

Continue building the capacity and develop HRHOver the past three years under Project HEART, EGPAF worked with the Schools of Medicine and Pharmacy, and INFS , contributing to the creation of a new generation of engaged HCW by providing pre-service training for 69 medical doctors, 151 social workers, and 25 pharmacists. Under COP12 (PY2 of Djidja), EGPAF will strengthen this network through Continuing Medical Education using information technologies such as e-learning combined with onsite thematic refresher trainings, building on a previous partnership with SIP , GroForMéd, or other professional associations .

EGPAF will also provide resources and TA to those three institutions to complete the ongoing process of creation of a post-graduation diploma based on the current curriculum, ultimately transferring program ownership to those institutions. EGPAF and other partners will then have the possibility of providing scholarships either to graduating students or to selected talented HCW in the field, moving the training model from push to pull.

Strengthening coordination of clinical practices and medical leadership at regional levelRegional level HSS is a top priority of the MOH. EGPAF discussed the issue with PNPEC and agreed to begin work in 1-2 regions during PY2. Documented lessons learned will allow the MOH to refine its strategy and more quickly scale up when Global Fund Round 10 is available. Under Project HEART EGPAF completed an assessment of the Bas-Sassandra regional health directorate (RHD) using an adapted CDC/Macro tool. During Djidja PY1, the RHD will advocate to have an adequate staffing structure consistent with MOH directives. EGPAF will train those staff.With COP12 funding during PY2, EGPAF plans to provide:Logistics support to establish a functioning Health Information System, including use of dateSupport for organization of coordination meetings involving all districtsSupport to perform routine supervision and control when requiredFormation of a multidisciplinary quality team to ensure that all services provided are consistent with national standards and procedures as defined by the MOHEGPAFs work will complement that of its local affiliate, Fondation Ariel, which will be in charge of capacity building at district and site levels in Bas-Sassandra region.

EGPAFs HIV Testing and Counseling (HCT) activities under Project Djidja COP12 will continue using provider-initiated testing and counseling (PITC) as a routine component at all entry point of service delivery, targeting both adults and children in ANC, maternity wards, TB clinics, STI clinics, inpatient wards, primary care clinics, and outpatient units. EGPAF will utilize five strategies for improving and increasing PITC, which will contribute to preventing new infections. These strategies include: 1) building the capacity of PITC providers; 2) increasing the number of children tested; 3) supporting the implementation of the national testing algorithm at all EGPAF-supported sites; 4) minimizing stockouts of testing supplies and reagents; and 5) increasing the number of sexual partners of PLWHA tested. These strategies will target adults, including pregnant women, couples, and children.The approaches for these strategies will include:1)Systematizing PITC at all EGPAF-supported sites by ensuring all sites have and use the national algorithm, training HCWs on the national algorithm, data collecting tools and developing a PITC checklist for use at sites;2)Providing mentorship and supportive supervision to HCWs to promote PITC in various entry points to care;3)Promoting EID through increasing access and use of PCR at all EGPAF-supported sites, and training HCWs to teach mothers to monitor the health of an exposed child until its final HIV status is determined;4)Increasing HTC for children through a family approach and by promoting PITC in pediatric settings;5)Supporting SCMS to prevent stockouts or find solutions earlier;6)Implementing systems to screen all partners of PLWHA visiting health centers and providing a letter of invitation for testing, organizing couples counseling sessions, and developing and disseminating awareness messages about testing and counseling targeting couples; and7)For people testing HIV-positive, ensuring linkages and referrals to care, support, and treatment services.Bi-directional referral systems will be put in place between PITC point of service delivery and care and treatment centers. To ensure effective linkages with care and treatment centers, frequent site and mentorship visits will occur and quality improvement action plans will be discussed and implemented. The supply-chain and clinical approach to HTC activities of EGPAFs Project Djidja in Vallée du Bandama will directly complement those of Project Keneyas community-based approach to increasing awareness of services that are available from EGPAF through both projects, incommunity and clinical settings.Implementation of HTC activities requires continuous capacity building activities for community health workers and HCWs on the benefits and impact of some HIV activities on wellbeing at individual and community level. EGPAF will do this through promotion of activities such as PITC, diagnosis and treatment of STIs, PwP, PMTCT, partner testing, early infant diagnosis, OVC support, and free and efficacious ARVs for children and adults.The monitoring and evaluation system that will support HTC activities will focus on the rollout of new harmonized national data collection tools and the training of HCW for improved completion of the tools. In addition, EGPAF will conduct a data quality assessment targeting data reported on testing of children.

PMTCT during COP12 will contribute to achieving one of the key national objectives to eliminate mother-to-child transmission of HIV (EMTCT) by reducing it to 5% by 2015. Target populations are women of childbearing age, their partners, exposed children, and other family members.At the institutional level, EGPAF will provide support to:oPre-service training institutions such as schools of medicine or social workers to strengthen the integration of HIV-related courses into student training curricula. The objective of this strategy is both to reduce in the long term the number of refresher trainings provided and to give necessary skills to newcomers to immediately start HIV/AIDS activities.oMinistry of Health (MOH) to finalize and disseminate national guideline documents (policies, technical procedures) and implement the national plan for EMTCT in all EGPAF-supported sites.At site level, EGPAF will build capacity of healthcare providers using several approaches: short-term classroom training sessions followed by immediate onsite immersion, providing access to scientific journals, and continued training via internet.Continuous improvement of PMTCT program quality is one of Project Djidjas objectives. EGPAF will:oIncrease the demand and utilization of services by the population through meetings to build the capacity of community members in activities run through the health centers: contents, advantages/benefits, costs, target population.oPromote re-testing of pregnant women in labor and delivery for those previously tested HIV-negative.oIncrease participation of partners of pregnant women in ANC, regardless of HIV status.oImplement 2010 WHO guidelines for PMTCT, adapted to the national context.oOptimize the biological follow-up of HIV-positive pregnant women by using point-of-care techniques for service delivery, including HIV screening using fingerprick rapid test and PIMA CD4 test machines.oOptimize the biological follow-up of HIV exposed children through dissemination of the new maternal-child health cards and increasing the number of HIV-exposed children identified through early infant diagnosis by broadening geographical coverage and especially decreasing turnaround time through the use of SMS printers.oStrengthen screening activities, particularly the promotion of couples HIV counseling and testing.oBuild on existing EGPAF capacity under Project HEART to reach underserved women who do not visit ANC through networks of community health workers already working in EGPAF-supported sites.Quality improvement (QI) activities for care and services linked to PMTCT will be done through analysis of routinely collected key indicators of the PMTCT cascade, in collaboration with other PEPFAR partners such as URC and Jhpiego. Quarterly and semiannual performance analysis workshops will be implemented with districts and regional directorates to produce QI plans.EGPAF will implement the following activities to improve retention in care:oOrganize a unique entry point into care after HIV testing (triage room) which will help to better direct, advise, support, and treat patients;oIntegrate testing, counseling, care, support, and treatment activities into existing services provided in sites, including maternal-child health and family planning services;oFacilitate identification of exposed children through dissemination of new PMTCT tools; andoSet up supervisory and QI teams within sites.

Target populations in coverage area of Djidja will include HIV-positive pregnant women testing at all entry points (ANC visits, labor and delivery) and men and women testing positive through other counseling and testing initiatives.EGPAFs strategy for implementing Adult Treatment activities under Project Djidja during COP12 will be based on three pillars: 1) access to care and integration of HIV activities within existing health services; 2) quality and supervision of services offered to PLWHA; and 3) sustainability and efficiency of services delivered.Activities under Pillar 1 will include building capacity of health care workers (HCW) to provide quality ART to patients in need, strengthen linkages between adult ART services and PMTCT services such as ANC, MCH, and family planning, as well as TB and reproductive health services. EGPAF will continue to advocate for task sharing and will be part of initiating this experience in supported sites to increase access to treatment for PLWHA.Under Pillar 2, by building capacity of district health management teams (DHMT) to improve the effectiveness of supervision, EGPAF will build toward a successful eventual transition of activities to national authorities. EGPAF will create SOPs for mentorship activities, assessment and improvement of data quality.

Onsite supervision will be provided by quality improvement (QI) teams that will be formed in EGPAF-supported districts and the largest ART sites. These teams will receive training and be provided with the most updated tools and SOPs available. These teams will complete mentorship visits, data quality analysis, data reviews, and be part of the supervision visit team with the DHMT.Quality of care initiatives for patients on ART include clinical and biological follow-up of side effects and eventual resistance, guided by the most recent national and WHO recommendations.Clinical outcomes and other performance data will be routinely tracked and evaluated through the quarterly collection of all required indicators by the district Strategic Information and Evaluation (SI&E) team.Djidjas overall retention rate of patients on ART will be increased through intensive follow-up of HIV-positive patients, including mandatory follow-up counseling sessions with trained CHWs. EGPAF will build local capacity using a variety of innovative approaches, including the district approach, community groups, and a QI approach using the EZ-QI tool. Other strategies will include conducting cohort studies in 95% of ART sites.

In addition to ART, EGPAF will provide other services such as cotrimoxazole prophylaxis, TB screening, nutritional support to eligible patients in collaboration with national nutrition program and UNICEF,PwP, insecticide-treated bednets, and WASH supplies.

The activities listed above will be supported by a strong system for monitoring and evaluation, in close collaboration with the national counterparts (DIPE, PNPEC). Focus areas for M&E will be:oImprovement of data collection process; roll out new harmonized national data collection;oExpansion of the national HIV drug tracking software (Simple-1/EDT) in non-computerized sitesoConducting of quarterly RDQAs and one annual DQA to improve data quality, measure performance, and improve quality at site and district level.

Under Project HEART, EGPAF experienced constraints associated with the scale-up and uptake of pediatric care and treatment such lack of access to early infant diagnosis (EID), insufficiently trained health care workers (HCW), lack of linkages between PMTCT and treatment, and the countrys non-implementation of the revised WHO 2010 recommendations.

Under COP11 funds, EGPAF through Project Djidja will focus on advocacy for implementation of the WHO recommendations, identification and training of regional and district EID experts to transfer ownership of service delivery, continuing medical education for current and new HCW, and working with the MOH to implement task sharing/shifting. Top priorities will also be integration in MCH and development of SOPs to allow furthertransfer of leadership and ownership to regions and districts. Under COP12 funds, Djidja will strive to consolidate the accomplishments of FY11 with a strong focus on the creation of effective and efficient models that will help speed up the scaling-up of pediatric treatment services at the decentralized levels. The model should network integrated MCH services with other child and mother welfare centers.

EGPAF will continue providing support through TA for planning, forecasting HIV supplies, QI, strengthening of the regional pool of HCW, and rolling out the WHO recommendations. EGPAF will ensure availability of SOPs, guidelines, and job aids. An area of special interest will be to address specific needs of adolescents on ART, such as treatment adherence, transition to adult care, and sexuality, particularly for teenage girls.

EGPAF will participate in quarterly regional and district meetings to ensure relevant challenges, identified through data analysis including quality indicators, are discussed and addressed. Regional and district health officers will be trained to lead such discussions and monitor site performance. To achieve this, clinical outcomes and other performance indicators will be routinely tracked and evaluated through the quarterly collection of all required indicators collected by the district Strategic Information and Evaluation team and sent to DIPE. Quarterly data analysis and reviews will contribute to high data quality.

Djidjas overall retention rate of children on ART will be increased through intensive follow-up of HIV-positive patients, HIV services (clinical settings, lab, pharmacy) network through mandatory follow-up counseling sessions with trained CHWs and peer educators for adolescent and appropriate referrals if necessary.EGPAF will provide services complementary to ART, including cotrimoxazole prophylaxis, TB screening, nutritional support to eligible patients by building HCW capacity in this area, in collaboration with national nutrition program and UNICEF, and other areas such as PwP, bed nets, WASH, and reproductive health counseling.All these activities will be supported by a strong monitoring and evaluation system in close collaboration with national counterparts: DIPE, PNPEC. Focus areas for M&E will be:oImprovement of data collection process; roll out new harmonized national data collectionoExpansion of the national HIV drug tracking software (Simple-1/EDT) in non-computerized sitesoCompletionof RDQAs (quarterly) and DQA once a year to improve data quality, measure performance and improve activities.