With FY 08 funds, USG technical staff will be supported and will continue to work closely with the

interagency management country team and HQ technical staff to provide technical assistance for the

design, implementation, and evaluation of PEPFAR-funded behavioral interventions designed to influence

HIV prevention behaviors, with primary emphasis on efforts to promote abstinence, fidelity, delay of sexual

debut, partner reduction, and related social norms. These are conducted in consultation with the Ministry for

the Fight Against AIDS, other technical ministries (Education, Health, Social Affairs, Human Rights, Youth

and Sport, etc.), non-governmental organizations (NGOs), multinationals, and bilateral organizations.

Ongoing specific activities will include:

- Participation in the behavior change communication (BCC) technical group and assistance, in

collaboration with JHU/CCP and the IEC/CCC unit of the DMS, in the mapping of AB activities implemented

by PEPFAR partners and the harmonization and standardization of BCC tools.

- Support for implementation of the life-skills curricula and coordination of the national BCC working group

- Identification of opportunities for targeted BCC.

- Supervision of official needs assessments.

- Coordination of activities among donors and partners, including UNICEF, UNAIDS, UNDP and PEPFAR-

funded partners Care International, FHI, PSI, JHPIEGO, ANADER, International HIV/AIDS Alliance, JHU-

CCP, and the ministries responsible for Education, Social Affairs, Health, and AIDS coordination).

- Develop a communications strategy, in coordination with JHU/CCP and REPMASCI (network of media

professionals and artists against AIDS in Cote d'Ivoire), to promote all PEPFAR activities.

PEPFAR CI will continue to support RIP+ (network of CBOs of people living with HIV/AIDS), REPMASCI,

and COS-CI (NGO collective against HIV, representing more than 400 organizations). PEPFAR CI will also

continue to support faith-based organizations (ARSIP, a recently created interfaith alliance of religious

leaders), youth organizations, and other community activists and leaders in mobilizing their communities for

the promotion of abstinence, fidelity, delay of sexual debut, and partner reduction in their communities.

With FY08 funds, the USG CI team will provide direct technical assistance to the Government of Cote

d'Ivoire and to our implementing partners, supplemented by targeted assistance from CDC headquarters, in

support of the country TB-HIV program. USG CI will support the in-country travel and logistics for all USG

CI TA and TA requested from HQ.

In the area of HIV-TB, the country team will provide ongoing technical assistance, augmented by technical

assistance from CDC HQ staff, to support the integration and scale up of routine counseling and testing

services at TB facilities, improved screening of HIV patients for TB, joint care of HIV and TB at joint-care

facilities, improved monitoring and evaluation of integrated HIV-TB services, and strengthening of

centralized and decentralized TB diagnostic services, including support for smear microscopy and TB

culture, and surveillance of multi-drug resistant TB.

With FY08 funds, the USG technical staff will continue to work closely with the interagency management

team and HQ technical staff to provide technical assistance for the design, implementation, and evaluation

of HIV counseling and testing interventions. USG technical assistance contributes to the strengthening of

national guidelines and adoption of routine testing policies at health facilities. USG staff consults with the

national VCT technical working group, expert HIV laboratory committee, and other technical forums to

assure the quality of decentralized HIV counseling and testing services. USG staff are providing ongoing

technical assistance for the inspection and supervision of HIV testing services performed at peripheral sites.

Specifically, USG staff will provide assistance in implementing the simple whole blood finger-prick rapid

testing algorithm. These efforts are conducted in consultation with the Ministry for the Fight Against AIDS;

other technical ministries (Health, Education, Family and Social Affairs); nongovernmental organizations,

multinationals, bilateral organizations (UNAIDS and other UN agencies); and PEPFAR-funded partners

(such as EGPAF, ACONDA-VS, Columbia-ICAP, Care International, FHI, International HIV/AIDS Alliance,

JHPIEGO, and ANADER).

Ongoing specific activities will include technical assistance to the MOH and other partners to improve the

quality and monitoring of counseling and testing through evaluation of existing counseling and testing

services. In conjunction with Liverpool, JHPIEGO and other partners, USG staff will provide technical

assistance for the integration of HIV testing at health-care service sites. USG staff will provide technical

assistance to strengthen training for professional health workers, professional counselors, lay counselors,

and labs technicians. This training will improve linkages to care and treatment services for people who test

HIV-positive.

These activities complement direct USG laboratory and other donor contributions to support the expansion

and reinforcement of a national network of laboratories involved in the development and implementation of

laboratory plans and resources for training, inspection, supervision, and monitoring and evaluation of

laboratory personnel and facilities.

With FY08 funds, USG technical staff will provide technical assistance, laboratory services and HIV

reference laboratory functions in support of all prevention, care and treatment services with direct

Emergency Plan (EP) support and will continue to work closely with integrated management team and HQ

technical staff to provide technical assistance and coordination in the area of HIV/AIDS care and treatment,

including assisting national programs with the development, implementation and evaluation of care and

treatment services in Cote d'Ivoire. These efforts are conducted in consultation with the Ministry for the fight

against AIDS, other technical ministries (Health, Education, Solidarity), non-governmental organizations

(NGOs), multinationals, and bilateral organizations.

Laboratory services provided by USG technical staff include provision of comprehensive biologic monitoring

for screening and follow-up of persons receiving ART, technical assistance to the MOH (PSP and national

HIV and TB care programs) to improve laboratories' commodities management system, procurement and

distribution of substantial laboratory and other supplies to support laboratory services, and management of

the national database of persons screened and taking ART at public sites, with progressive transfer of

service-delivery functions to the national laboratory system.

In addition, USG assists host government, non-governmental organizations and donor partners (e.g.

UNICEF, UNAIDS, UNDP), and EP-funded partners (CARE, FHI, JHPIEGO, ANADER, HOPE Worldwide,

Alliance CI, the Ministry responsible for the fight against AIDS, and other technical Ministries) in continued

cooperation and coordination of care and treatment. USG staff provides direction to collaborators on USG

policies, strategies, priorities, guidelines, and reporting requirements related to ART services.

USG staff provides advice to country partners on the matters of medical and scientific policy and practices

associated with program management and operational support for care and treatment services. USG staff

substantially contributes to the planning and implementation of policies to ensure the ongoing development

of programs to improve health care management and delivery systems of the national public health

activities of Cote d'Ivoire. USG staff provides advice and guidance regarding internal and external public

health programmatic design, procedures, protocols, and studies as well as technical and administrative

policies among various levels of stakeholders. USG staff supports coordination and provides technical

assistance to reinforce public-private partnerships efforts to expend an effective and comprehensive

HIV/AIDS response in the workplace, including facilitating the coordination and jointed actions related to

HIV/AIDS among and between companies, between public and private sectors. In coordination with

UNAIDS, ILO, and other bilateral technical cooperation institutions, this activity will support innovative

public/private/NGO partnerships to promote HIV/AIDS sustainable and quality health services with

expanded coverage, including care and treatment to family members of workers and surrounding

communities.

Title: Evaluation of transmitted HIV drug resistance using specimens from unlinked HIV serosurvey

Budget: $175,000 in FY07 carryover funds.

Project Description:

The use of ARV drugs has been associated with the development of HIV drug resistance (HIVDR). Because

of the high mutation rate of HIV and because of the lifelong treatment of the disease, it is expected that

some degree of HIVDR will occur among persons in treatment even if appropriate regimens such as

HAART are provided and good adherence is supported. Antiretroviral treatment has been introduced in

Côte d'Ivoire, specifically in Abidjan since 1998.

Hypotheses are the followings:

1. During the first ten years during which ART is being rapidly scaled up in Côte d'Ivoire, well-functioning

ART programs will result in transmitted HIVDR prevalence remaining below 5% for each drug used in the

standard first-line regimen(s).

2. If transmitted HIVDR prevalence is > 15% to a particular drug or drug class in Abidjan, specific public

health actions will be taken to minimize the emergence and transmission of HIVDR.

The purpose of the project is to evaluate the extent of transmitted HIV drug resistance in Abidjan, the

economical capital of Côte d'Ivoire, where the prevalence of HIV drug resistance is likely to be higher, than

in other areas of the country where antiretroviral treatment (ART) is not, or previously has not been, readily

available to the treatment-eligible population.

Results will alert planners, clinicians, and program staff if additional measures should be considered to

prevent unnecessary emergence of HIVDR and to evaluate whether initial ART regimens will continue to be

effective.

Methodology:

Study design/location

The study design is a cross-sectional survey, utilizing data and portions of eligible specimens collected in

HIV sentinel serosurvey.

In Côte d'Ivoire, the target population for sentinel serosurveys is made up of women attending antenatal

clinics (ANC), in both rural and urban areas. In order to restrict the evaluation to persons relatively recently

infected with HIV, eligibility is restricted to specimens from persons < 25 years of age, and, in ANC, to

women in their first pregnancy. No client data will be collected other than those that are collected routinely

for sentinel serosurveys.

Population of Interest:

For this survey, the relevant variables are age group, number of previous pregnancies, and, if available,

information on last negative and first positive HIV tests and previous ART exposure. The duration of this

study is 6 months; eligibility criteria are as follows:

1. Women whose age is < 25 years

2. Women in their first pregnancy.

3. The specimen, when tested for the HIV serosurvey, is confirmed as HIV-1 positive

Using a method based on binomial sequential sampling, up to 47 consecutively collected eligible specimens

will be used. One milliliter of serum is recommended for HIV drug resistance testing. HIV-RNA will be

extracted and amplified for genotyping in the laboratory of CDC/RETRO-CI in Abidjan. The protease region

and relevant positions in the reverse transcriptase region of the pol gene will be sequenced to detect

mutations known to be associated with resistance to drugs in standard first line regimens and other drugs of

interest.

The prevalence of resistance will not be estimated precisely, but will be rather classified (for each drug or

drug class) as <5%, 5-15%, and > 15%. If prevalence is classified as <5% to all relevant drugs, the survey

is repeated two years later. If prevalence is classified in the higher categories, additional surveys or more

resource-intensive surveillance may be required, as well as additional public health actions.

HIV-1 subtype distribution will also be evaluated using the nucleotide sequence information obtained in the

HIVDR-TS

Five ANC sentinel sites in Abidjan district will be involved in this survey; the projected eligible sample size

from all these ANC sites is 60 eligible specimens.

The ability to obtain 60 eligible HIV positive specimens depends upon the sample size of the HIV

serosurvey in the geographic setting, the proportion of women < 25 years of age in their first pregnancy

enrolled in the previous serosurvey in the setting and the HIV prevalence among women in the age group of

interest. According to 2005 ANC survey in Côte d'Ivoire, the 2 sentinel sites in Abidjan had a total

serosurvey samples of 600 pregnant women; among them, we found 40% proportion of pregnant women

(281) aged under 25 years and in their first pregnancy. Among these 281 young women, 19 were HIV

positive; so to obtain 60 eligible HIV positive specimens, we need to involved 3600 pregnancy women in all

the five sentinel sites selected in Abidjan for this study.

Budget Justification:

Fringe benefits: $2,000

Training, counseling and testing support, psychological support, and monitoring: $50,000

Travel and supervision: $60,000

Laboratory supplies and reagents: $13,000

Other costs (per diem, lodging, conference room rental, transportation,

training supportive documents, incentives for clients, tools for results

communication ): $50,000

Total: $175,000.00

Activity Narrative: Title: Evaluation of transmitted HIV drug resistance using specimens from unlinked HIV serosurvey

The PEPFAR Cote d'Ivoire USG interagency team continues to use innovative approaches to improve

management and operations while minimizing costs. The PEPFAR CI team was built on the platform of the

CDC Projet RETRO-CI, which was established in 1988 as a research collaboration between the CDC and

the Cote d'Ivoire Ministry of Health to study the HIV epidemic in West Africa. Among the highlights in the

history of RETRO-CI are interventional research studies which have led to international policy

recommendations on HIV care and treatment, including short course zidovudine (AZT) as a safe and

effective intervention to reduce mother-to-child transmission and cotrimoxazole prophylaxis as a simple

intervention to reduce hospitalizations and mortality among HIV-infected persons. In 2000 Projet RETRO-CI

expanded its mission to include programmatic activities as part of the CDC-Global AIDS Program and with

the advent of PEPFAR in 2004 the mission of the laboratory, SI and administrative staff became almost

exclusively focused on the support of PEPFAR programmatic activities. In the absence of a bilateral USAID

mission in Cote d'Ivoire, the CDC platform (including administrative, management, technical, and motor pool

staff) has been used to develop an interagency team structure that is fully-integrated and without

redundancy. While the CDC serves as the primary administrative mechanism for the hiring of local and

international technical and administrative staff, the Cote d'Ivoire USG interagency team is leveraging USAID

contracting mechanisms as needed to expedite the hiring of staff.

In its efforts to ensure program performance at a reasonable cost, optimizing USG human and financial

resources, the PEPFAR USG CI team continues to implement a fully coordinated interagency approach that

includes: 1) weekly PEPFAR-CI (interagency) senior management meetings, 2) capitalizing on laboratory

and informatics expertise at Projet RETRO-CI through direct technical assistance and service to our

implementing partners; 3) providing management and technical assistance to all EP funded partners via an

integrated team of project managers and technical advisors (regardless of funding agency); 4) joint agency

staffing positions (such as the proposed new FY08 positions: a project management specialist and a

community liaison specialist); 5) hosting regular program reviews of all implementing partners that combine

portfolios from all in country agencies and, 5) leveraging USAID contracting mechanisms for Fast Track and

longer term positions in order to address staffing needs in country.

These steps facilitate optimal management, coordination, and performance of USG funded activities and

results in a decrease in the number of USG directly supported staff, reduction in redundancies,

capitalization of technical strengths, improvements in coordination and greater compliance with USG

financial requirements.

With a significant increase in the number of implementing partners and activities supported by PEPFAR

Cote d'Ivoire (along with a significant increase in budget—a near tripling of the PEPFAR-CI budget from

FY06 to projected FY08), there is a need for additional staff to responsibly manage the growing portfolio.

Hence, the human capital cost for USG Cote d'Ivoire's management and operations continues to increase.

A large percentage of the management and operations budget is driven by ICASS and OBO charges

associated with the construction and now maintenance of the current embassy compound (see ICASS/OBO

narrative). The chronic politico-military crisis, while slowly improving, is yet to be resolved and has

increased transactional costs including the costs of goods and services. Security in Cote d'Ivoire remains a

concern and general operations costs for the USG reflect additional expenses for security and

communications.

With the successful recruitment of multiple senior positions, including a permanent PEPFAR DDO, SI

Liaison/Branch Chief, Care and Treatment Branch Chief, Program Management Branch Chief, and

Laboratory Branch Chief, and the creation of a number of program manager, technical advisor, and

administrative support staff positions in 07—in conjunction with regular step/performance increases and the

overall PEPFAR interagency salary costs have increased.

PEPFAR-CI has focused considerable attention and invested significant human resource time into the

development of high level LES position descriptions for technical and program management staff. PEPFAR

-CI, with support of the Chief of Mission, is working closely with HR staff at the Embassy to address

concerns with the State Department CAJing system to achieve grading which accurately reflects the

responsibilities and competencies of the positions. For FY08 15 new PEPFAR interagency positions are

anticipated (described in detail in the Management and Staffing Overview).

Even though CI appears to be emerging from a long politico-military crisis, the security situation remains of

concern and the post remains a critical threat post and is currently "adult only" with minor dependents not

permitted. This coupled with French language requirements creates additional challenges in filling

international positions. Retaining LES staff remains a challenge as a result of salary limitations, CAJE

classifications and growing competition with other donors and implementing partners for a limited pool of

highly competent technical staff. In FY 07 two newly hired key LES leadership and technical advisors

accepted positions in other countries because of greater opportunities for professional growth and financial

security. In addition, the team is losing a critical operations management position due to retirement.

Despite efforts in FY07 to implement appropriate preventive "mental health" strategies to protect staff from

burn-out associated with living and working in a chronically high stress environment, these were difficult to

implement due to staff shortages, change in senior USG leadership, and a rapidly expanding program which

is responding to change in the politico-military situation. With recent success in recruiting a number of

senior staff positions, FY08 offers the promise of a USG team that is both broader and deeper in its

program management capacity, which should pay dividends not only for the management of our PEPFAR

programs, but also for the USG team itself.