CONTEXT The goal of the Making Medical Injections Safer (MMIS) project is to provide a rapid response to prevent the transmission of HIV and other bloodborne diseases by improving the safety of medical injections. In Côte d'Ivoire MMIS implementation environment is marked by a political crisis dating back to September 2002 and the resulting disruption of national health system with a sometimes precarious security situation. Despite these security concerns, the program is expanding in scope. To date (September 2006) 24 districts representing 28% of country total districts are covered by MMIS activities. The program benefits from a collaborative work environment with local partners and responsive technical support from MMIS/Washington as well as USG technical staff represented by CDC/Projet RETRO-CI. MMIS works with WHO, UNICEF, and other partners to complement safe injection activities implemented by the Ministry of Health.

Project major achievements from 2006 are following:

Capacity Building: 3311 health workers and waste handlers were trained in injection safety and waste management (ISWM) from October 2004 to September 2006 representing 93% (3311/3564) of HCWs and waste handlers in the 501 MMIS covered public sector health facilities in 24 districts. Logistics Management: Safety boxes are used in all 24 districts. 18 districts have been supplied with safety syringes (auto-disable and retractable types). The program works through the MOH supply distribution network which is managed by the Pharmacie de la Santé Publique (PSP). Behavior Change and Communication: 1875 health workers and waste handlers were trained and job aides and other communication aides were produced, tested and disseminated in all program intervention districts. Waste Management: MMIS assisted districts in developing safety box collection plans. This involves transportation of safety boxes to incinerator or other destruction sites. Monitoring and Evaluation: Supervision visits were conducted with district supervisors in covered districts, focusing on key indicators.

The COP07 is consistent with MMIS 2005-2009 strategic plan and will expand to nationwide coverage, build on the project's successes, and implement interventions that will continue beyond the life of the project. In FY07, another 11 health districts will be added, bringing the national coverage to 41% (78% of the districts in the government-controlled south). The project will also focus on coordinating activities with key IS partners at national level. Collaboration with CDC and other PEPFAR partners remains a priority and will be achieved through regular meetings.

Globally, MMIS strategies and major activities for 2007 are as follows:

Improving safe injection practices through capacity building: Distribution of procedures and guiding principles on infection prevention and injection safety; Integration of injection safety in pre-service training institutions; Development of action plans and organization of training sessions in additional districts, where an average of 100 health workers per district will be trained, representing 75-100% of health workers in 11 districts; Training sessions for those new recruits or displaced health workers in the covered districts.

Improve availability of safe injection supplies in all health facilities by working with logisticians at district level: Development of a logistics plan with key partners; Distribution of ISWM equipment in target districts; Promote the use of logistics management information system to monitor distribution and collect consumption data to compare utilization for all types of syringes; Use of consumption data of syringes and safety boxes to inform the PSP feasibility study for future MSPP procurement of safe injection equipment.

Promote the rational use of injections through targeted behavior change and advocacy strategies: Organization of a scientific forum on injection safety issues and rational use of injections; Advocacy meetings with authorities in target districts; Documentation of behavior changes among prescribers through a prescription record review; Documentation of behavior

changes among the community regarding demand for injections through a community survey; Develop/revise standard treatment guidelines for 5 key health programs; Organization of a multimedia campaign to promote injection safety.

Development and reinforcement of waste management systems: Work with the national waste management task force to develop a national WM plan including relevant procedures for waste collection, transportation and destruction at district level; Introduce a waste segregation system in 2 pilot districts, including provision of coded waste bins; Provide protective equipment to waste handlers; Work with local manufacturers to promote local production of safety boxes; Provide assistance to health districts in the use, maintenance and repair of incinerators.

Promotion of health worker safety and prevention of needlestick injury: Organize quarterly sensitization meetings with MOH and professional associations to promote health worker hepatitis B vaccination; Provide waste handlers in 25 districts with personal protective equipment.

Gather information to inform the development of strategies to improve IS in informal sector Based on the analysis of in-country documentation on the informal sector conducted in FY06, implement the Cote d'Ivoire adaptation of the Informal Sector Focus Group Discussion Guide and Protocol; Develop national strategies to address injection safety issues in informal sector.

Coordination, monitoring and evaluation through: Meetings of the National Injection Safety Committee and Task Force working groups in each technical area of the project (Procurement and Supply Management, Rational Use of Injections and Waste Management); Reinforcing collaboration with CDC and other PEPFAR partners through participation in meetings and sharing of experiences; Development of quarterly and semiannual reports on project implementation; Monthly monitoring meetings with the CDC/Abidjan focal point for infection prevention; Participation in coordination meetings at national level through the Expanded Committee review of PEPFAR program interventions; Monitoring of training data through the use of the JHPIEGO TIMS tracking software; Organization of a meeting among the intervention districts to exchange experiences and update district microplans; Organization of supervision visits.

MMIS expansion mechanisms in districts controlled by "Forces Nouvelles" will be coordinated with PEPFAR partners and international institutions working in these zones such as UNICEF and Medecins Sans Frontières.

Targets

Target Target Value Not Applicable Number of individuals trained in medical injection safety 1,100

Table 3.3.05: Program Planning Overview Program Area: Condoms and Other Prevention Activities Budget Code: HVOP Program Area Code: 05 Total Planned Funding for Program Area: $ 3,675,000.00

Program Area Context:

Background

The 2005 national AIDS Indicator Survey has provided critical information about the HIV/AIDS epidemic in Cote d'Ivoire, permitting better targeting of prevention efforts. Within an adult HIV prevalence of 4.7%, females in all age groups were far more likely than males to have HIV (6.4% vs. 2.9%). Prevalence peaked among women aged 30-34 at 14.9%, vs. 5.6% of men. Male prevalence may be mitigated by near-universal (96%) circumcision. Geographic differences included marginally higher prevalence in urban compared to rural settings and marked regional differences, from 1.7% in the Northwest to 5.8% in the South 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. Almost one-third (31%) of unmarried women aged 15-19 reported having a sex partner who was at least 10 years older. One-third of married women were in polygamous marriages. The population aged 15-49 reported that 5% of females and 31% of males had two or more sexual partners in the previous year; 33% of females and 58% of males reported a risky (non-marital/non-cohabitating) sex partner; and 66% of females and 48% of males did not use condoms with risky sex partners. Access to condoms was not reported as a constraint, but access to low-cost lubricants was. BSS surveys indicate that HIV rates have declined among female sex workers, who have increased their use of condoms with clients but not with regular partners. While only 2% of men reported paying for sex, available evidence suggests that the contribution of transactional sex to the epidemic is inadequately understood but substantial.

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 sexual behavior and condom use were more likely among better-educated, urban, wealthier people who lived outside the North-West. Attitudes reflecting intolerance conducive to HIV stigma and discrimination were widespread, particularly among women. More than one-third (34%) of women reported having no access to any mass media.

FY06 Response

At national and local levels, Ivorian government response is marked by strong commitment and limited resources. The Ministry of the Fight Against AIDS (MLS), charged with coordinating all HIV/AIDS activities, drafted a new HIV/AIDS National Strategic Plan for 2006-2010 that emphasizes behavior change to decrease HIV transmission. Strategies were comprehensive, targeted, and complementary and included delay of sexual debut and promotion of fidelity, partner reduction, consistent and correct use of condoms, individual and couple HIV testing, and prevention and treatment of STIs, as well as addressing relevant gender and cultural issues and stigma and discrimination.

The USG-CI pursues a comprehensive ABC prevention approach. For Cote d'Ivoire, traversing a military and sociopolitical crisis, large-scale but targeted prevention interventions are critical to use scarce resources to mitigate the impact on vulnerable subpopulations at high risk of acquiring HIV and contributing disproportionately to the national and regional HIV epidemics, including the uniformed services and transactional sex workers.

The national prevention strategy and the 2005 BCC strategy include a sequenced and targeted ABC approach. Individual, couple, and family CT is seen as a key primary prevention tool as well as being essential for secondary prevention and to create linkages to care and treatment. Promotion of couple testing is intrinsically linked to promotion of mutual faithfulness and of condom use within sero-discordant couples. Promotion of abstinence and fidelity among youth is linked to condom education for those at high risk.

The program continues to build on the success of targeted prevention campaigns. EP-supported interventions target the uniformed services and ex-combatants, truckers, displaced and mobile populations, transactional sex workers and their clients, sexually active in- and out-of-school youth, and health- and education-sector workers. Cooperative agreements launched in September 2005 have expanded ABC activities and promotion of HIV testing and STI management among underserved populations (e.g. in rural and rebel-controlled areas and for uniformed services). For transactional sex workers and truckers, the USG continues to support services, including static clinics with peer outreach, providing 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 USAID and World Bank regional projects targeting transport routes.

FY07 Priorities

Existing interventions are being expanded to extend the scope of services and geographic coverage in 2007. Based on lessons learned, the 2005 AIS and other available data, and the new national strategic plan, the USG will focus on the following prevention priorities:

• Targeted, locally appropriate responses to address major sources of new infections. With BCC committee attention to matching interventions and documented need, BCC campaigns will work to increase knowledge and safer sexual behavior in underserved communities (e.g. in the North and in rural areas) as well as in targeted subpopulations (e.g. sex workers, truckers, uniformed services, life skills for in- and out-of-school youth, stigma reduction and positive gender and cultural norms among religious and other opinion leaders). • Targeted bridge-population mass-media campaigns. The USG will support the design of mass-media campaigns to reach those engaged in highest-risk behaviors. For example, men who pay for sex will be targeted with messages about the risks associated with transactional sex, including with partners they might not consider commercial sex workers. • BCC and sensitization activities targeting CSW. The risks of inconsistent condom use with clients and with regular partners will be addressed through focused sensitization, including BCC materials at clinics that provide services to female CSWs. • Secondary HIV prevention among HIV-infected individuals and sero-discordant couples, with identification of and care for infected and affected family members, is a major focus for 07, representing a cross-cutting theme that provides opportunities to link prevention, care, and treatment services. • Operations, qualitative, and quantitative research. To design more effective programming, more formative research is needed to understand how Cote d'Ivoire's socio-economic and political crisis has shaped or reinforced risk behaviors. The addition of a behavioral scientist to the team and new data will allow field research into issues such as the dynamics between non-Ivorian sex workers/clients and local populations, the dynamics of transactional and cross-generational sex, and potential structural interventions to reduce youth vulnerability to cross-generational and transactional sex.

Coordination The USG, the major donor/partner supporting HIV prevention activities in the country, pursues complementarity and coordination with other partners focusing on condom provision, child protection, sexual violence, reproductive health, and gender issues, including UNICEF, KfW, and UNFPA. Key institutional partners include the ministries of AIDS, Education, Social Affairs, Health, and Youth, as well as PLWHA networks. Coordination with partners on the BCC committee and other forums is improving.

Sustainability The USG continues to promote sustainability by building the capacity of indigenous organizations to implement programs and raise funds. The USG is transferring technical, financial, programmatic, and M&E skills from international organizations to local CBOs, NGOs, FBOs, and ministries to manage and be accountable for implementing activities and achieving intended results.

Program Area Target: Number of targeted condom service outlets 1,853 Number of individuals reached through community outreach that promotes 554,735 HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention through other 3,139 behavior change beyond abstinence and/or being faithful

Table 3.3.05: