ICAP-Columbia University, a new partner in Cote d'Ivoire, received plus-up funds in FY07 to help the Ivorian

Ministry of Health to expand the availability of a basic package of HIV services at health facilities throughout

the country. By the end of FY07, ICAP anticipates initiating CT, PMTCT, palliative care, and ART services

at five sites and conducting baseline assessments and training at five more sites.

In FY08, ICAP will support this package of services at all 10 FY07 sites and expand to an additional 34, for

a total of 44 sites providing 27,750 pregnant women with HIV counseling and testing and 1,900 pregnant

women with a course of ARV prophylaxis. ICAP will support sites to provide family-centered PMTCT

services, using antenatal care (ANC) and other mother-child health (MCH) services as a key entry point.

ICAP's capacity-building approach, focusing on district- and facility-level systems strengthening and

provider training and mentoring, will help ensure long-term sustainability. Interventions will include:

• Conducting initial assessments and developing work plans for establishing and/or improving PMTCT

services. Sites that are providing single-dose nevirapine will be supported to shift to a PMTCT-Plus model

of care. This will include developing a plan for reorienting services to ensure that the PMTCT-Plus cascade

is effectively implemented (e.g. ensuring CD4 testing the same day as HIV test results, coordinating ANC

visits with care and treatment visits for pregnant women initiated on ART , etc).

• Providing training and on-site clinical mentoring for 132 nurses, social workers, counselors, and outreach

workers on PMTCT-Plus and conducting on-site mentoring for initiation of services and following

implementation.

• Supporting sites to provide quality group and individual pre- and post-test counseling to maximize

acceptance of testing, receipt of results, and enrollement in and adherence to the PMTCT program. An opt-

out testing approach will be adopted. Counseling and testing will also be provided to pregnant women

presenting to the facility for the first time during labor.

• Assisting sites to implement support groups for HIV-positive pregnant women. ICAP will collaborate with

Intrahealth to implement the Mothers to Mothers approach at selected sites.

• Supporting sites to develop systems to ensure that HIV-infected pregnant women are promptly assessed

for ART eligibility, receive routine CD4 cell count testing, and are provided with the array of services

appropriate to their disease stage, including ART when indicated. Another important component of the

services will be provision of intermittent prophylaxis for malaria (if not on cotrimoxazole).

• Supporting sites to provide enhanced counseling on disclosure, couples counseling, prevention, nutrition,

infant feeding, and adherence. In line with a family-centered care model, women will be strongly

encouraged and supported to bring their children and other family members to the facility for testing.

• Developing systems for linking PMTCT, care, and ART services to ensure that all pregnant women testing

HIV-positive are enrolled in care and treatment and receive ongoing care after delivery.

• Supporting facilities to establish systems for identifying and tracking women lost to follow-up and

supporting adherence to ARV prophylaxis and ART, including linkages to PLWHA organizations and

community-based support programs.

• Supporting sites to establish/strengthen links with community-based organizations to ensure community-

based patient support to ensure adherence to prophylactic regimen, nutritional support, and other services.

ICAP will introduce a community resource mapping tool and support sites to develop formal agreements

and referral systems with relevant organizations.

• Ensuring effective exposed-infant follow-up, including initiating 90% of all exposed infants on

cotrimoxizole, growth monitoring, and early infant diagnosis using PCR. ICAP will support sites to enroll

infants testing HIV-positive into care and treatment services. Sites will also create linkages with community-

based OVC services for all exposed and infected children.

• Collaborating with districts to support the initiation of PMTCT services and ongoing supervision and quality

improvement.

• Supporting sites to implement patient record-keeping systems and databases and to summarize and

analyze data for routine reporting, using national tools. A data quality assurance system will be

implemented, and ICAP technical advisers will assist sites to analyze data regularly to assess program

quality. This will include the introduction of registers that will allow sites to track mother/infant pairs

throughout the PMTCT cascade of services. ICAP will meet regularly with the MOH to provide feedback on

PMTCT-related M&E tools and approaches to help improve the national system of data collection and

reporting.

• Collaborating with SCMS and the Public Health Pharmacy (PSP) to ensure effective forcasting of needed

medications and test kits and to ensure timely delivery and managent of stocks.

At all PMTCT, ART, and CT sites, ICAP will provide - either through direct hire or by contracting with

individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for PLWHA and their children. ICAP will engage

enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and palliative care

funds) to allow every site to provide this prevention and referral package to all clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for BCC interventions

focusing on ABC methods of risk reduction, as well as partner testing and STI prevention and care. HIV-

positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will include

ABC prevention interventions (including disclosure, partner and family testing, and STI prevention and care)

and referral to community-based OVC and palliative care services to address family and individual care

needs. Where possible, family-planning services will be provided through wraparound programming by non-

PEPFAR funded partners, and condoms will be provided free of charge.

All HIV-positive clients will be offered information about and referrals to specific community-based OVC

care and palliative care services tailored to their needs. ICAP will ensure that community-based services

capable of meeting these needs are identified, and ICAP will be responsible for monitoring and reporting on

referrals according to a nationally standardized referral system.

Facility-based health services represent a critical opportunity to impact client behavior through clear,

authoritative health messages delivered in one-on-one or small-group settings, as well as to connect clients

effectively with community-based care services. To use the opportunity to reduce risk behavior and thus

HIV transmission, all PEPFAR Cote d'Ivoire ART and PMTCT service providers will ensure that their

package of services includes HIV prevention behavior-change communication promoting risk reduction

through abstinence, fidelity, correct and consistent condom use, status disclosure, partner testing, and STI

prevention and care targeting both HIV-positive and HIV-negative clients. In addition, they will ensure that

all HIV-positive clients are offered effective, monitored referrals to community-based OVC and palliative-

care services.

HIV-negative clients at PMTCT and CT sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a community counselor for

behavior change communication interventions, delivered individually or in small groups, focusing on risk

reduction through abstinence and fidelity, with correct and consistent condom use for those engaged in high

-risk behavior, as well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT and ART sites:

Addressing prevention with HIV-positive patients is an important part of a comprehensive prevention

strategy. Through healthy living and reduction of risk behaviors, these prevention interventions can

substantially improve quality of life and reduce rates of HIV transmission. The goal of these interventions is

to prevent the spread of HIV to partners and infants born to HIV-infected mothers and protect the health of

infected individuals.

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a community

counselor for individual counseling that will include HIV prevention interventions and referral to community-

based OVC and palliative care services. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Family-planning counseling and services will be provided to patients and their

partners through wraparound programming by other non- PEPFAR funded partners. Condoms will be

provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. ICAP will ensure that

community-based services capable of meeting these needs are identified and will be responsible for

monitoring and reporting on referrals.

ICAP will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services.

This entry represents the Abstinence and Being Faithful portion of the comprehensive prevention package.

This programmatic area is addressed in several components of the intervention. Counselors will be trained

to assess and address sexual risk behavior and to deliver tailored AB messages using culturally appropriate

visual aids. In each of these interventions, patients are encouraged to remain abstinent to protect their own

health and avoid transmission to partners. Patients who are sexually active are also encouraged to remain

faithful to one partner. Abstinence is also promoted in the family planning and STI trainings as a method of

preventing pregnancy and STI transmission.

ICAP will report to the USG strategic information team quarterly program results and ad hoc requested

program data. To help build and strengthen a unified national M&E system, ICAP will participate in quarterly

SI meetings and will implement decisions taken during these meetings.

Facility-based health services represent a critical opportunity to impact client behavior through clear,

authoritative health messages delivered in one-on-one or small-group settings, as well as to connect clients

effectively with community-based care services. To use the opportunity to reduce risk behavior and thus

HIV transmission, all PEPFAR Cote d'Ivoire ART and PMTCT service providers will ensure that their

package of services includes HIV prevention behavior-change communication promoting risk reduction

through abstinence, fidelity, correct and consistent condom use, status disclosure, partner testing, and STI

prevention and care targeting both HIV-positive and HIV-negative clients. In addition, they will ensure that

all HIV-positive clients are offered effective, monitored referrals to community-based OVC and palliative-

care services.

HIV-negative clients at PMTCT and CT sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a community counselor for

behavior change communication interventions, delivered individually or in small groups, focusing on risk

reduction through abstinence and fidelity, with correct and consistent condom use for those engaged in high

-risk behavior, as well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT and ART sites:

Addressing prevention with HIV-positive patients is an important part of a comprehensive prevention

strategy. Through healthy living and reduction of risk behaviors, these prevention interventions can

substantially improve quality of life and reduce rates of HIV transmission. The goal of these interventions is

to prevent the spread of HIV to partners and infants born to HIV-infected mothers and protect the health of

infected individuals.

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a community

counselor for individual counseling that will include HIV prevention interventions and referral to community-

based OVC and palliative care services. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Family-planning counseling and services will be provided to patients and their

partners through wraparound programming by other non- PEPFAR funded partners. Condoms will be

provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. ICAP will ensure that

community-based services capable of meeting these needs are identified and will be responsible for

monitoring and reporting on referrals.

ICAP will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services.

This entry represents the Other Prevention portion of the comprehensive prevention package. This

programmatic area is addressed in several components of the intervention. Counselors will be trained to

assess and address sexual risk behavior and to deliver tailored OP messages using culturally appropriate

visual aids. In each of these interventions, patients are encouraged to remain abstinent to protect their own

health and avoid transmission to partners. Patients who are sexually active are also encouraged to remain

faithful to one partner. Furthermore, the prevention approach, "positive prevention," aims to protect the

health of HIV-infected individuals and prevent the spread of HIV to sex partners and infants. Because an

HIV-positive person is involved in the transmission of each new infection, prevention interventions aimed at

people infected with HIV can have a larger effect on disease spread than comparable efforts aimed at

people who are not infected. This makes positive prevention an essential part of a comprehensive

prevention approach. Key prevention steps at each clinic visit will be the delivery of behavioral prevention

messages (including addressing issues relevant to discordant couples), STI management, discussing family

planning needs, and assessment for heavy alcohol use and ARV adherence.

ICAP will report to the USG strategic information team quarterly program results and ad hoc requested

program data. To help build and strengthen a unified national M&E system, ICAP will participate in quarterly

SI meetings and will implement decisions taken during these meetings.

Noted April 16, 2008:

This funding represents a percentage of Alliance CI 's palliative care funds reprogrammed to ICAP

Columbia University to provide financial, programmatic, technical and overall capacity building support to

subpartners who received grants in FY 07 to continue providing uninterrupted palliative care services in the

zones ICAP Columbia University is working. ICAP will also provide subgrant funding and technical

assistance to several subpartners formerly supported through Alliance National Contre le SIDA.

ICAP-Columbia University, a new PEPFAR partner in Cote d'Ivoire, received FY07 plus-up funds to help the

Ivorian Ministry of Health to expand provision of a basic package of HIV/AIDS services at health facilities in

the midwestern part of the country. By the end of FY07, ICAP anticipates initiating HIV counseling and

testing, PMTCT, palliative care, and ART services at five sites and conducting baseline assessments and

training at five more sites. In FY08, ICAP will support this package of services at all 10 FY07 sites and

expand to an additional 34 sites, for a total of 44 sites.

Palliative care services for HIV-positive individuals will be provided by a multidisciplinary team of providers,

will focus on caring for the whole family, and will be strongly integrated with CT, PMTCT, and ARV services,

as well as identification and referral to appropriate services for orphans and vulnerable children (OVC). By

February 2009, the 44 facilities will have enrolled 15,500 HIV-infected individuals into palliative care

services.

ICAP's capacity-building approach, focusing on district and facility-level systems strengthening, and

provider training and mentoring, will ensure long-term sustainability.

In FY08, palliative care interventions will include:

• Support sites to recruit and retain staff for palliative care service provision. ICAP will work with districts and

facilities to identify staff needs and find creative solutions for augmenting staff. This may include hiring staff

directly and placing them at the site for positions such as data clerks, or paying for clinical staff for short

periods of time while the district advocates for additional funding for needed positions from the MOH.

Providing the necessary training, resources, and tools needed for staff to provide quality palliative care

services will help motivate staff and increase retention.

• Train at least 170 doctors, nurses, social workers, counselors, and outreach workers to deliver palliative

care. ICAP will conduct intensive on-site mentoring during the initiation of services and periodic follow-up

training and mentoring thereafter.

• Support sites to identify HIV-positive patients by strengthening HIV counseling and testing interventions,

including traditional VCT and routine provider-initiated CT (see Counseling and Testing section). ICAP will

also support sites to publicize the availability of palliative care services in the communities they serve.

• Support sites to develop patient-flow algorithms, patient-appointment systems, and protocols related to

palliative care (e.g. CD4 schedule for pre-ARV patients, OI prophylaxis and treatment, etc).

• Support the formation and functioning of Multidisciplinary Team Meetings to discuss complicated cases,

including those failing treatment, and to coordinate individual patient care.

• Promote OI prophylaxis and treatment in accordance with MOH/National HIV/AIDS Care and Treatment

Program (PNPEC) guidelines. Similarly, TB screening and isoniazid prophylaxis will be promoted for HIV-

infected adults and children. Attention will be given to the issue of HIV/malaria co-infection, and the use of

bednets (and IPT if part of revised national guidelines) will be included in the standard operating procedures

of HIV clinics.

• Ensure strong linkages between palliative care services and other services within the facility, such as in-

patient wards, the outpatient department, VCT, PMTCT, TB, under-5 clinic, and family planning. HIV testing

will be routinely offered to all patients in these services, and those testing HIV-positive will be immediately

enrolled in the care and treatment program and initiated on ART if eligible. HIV Program Management

Committees, including key staff representing various departments, will be established and will meet

regularly to coordinate services and cross-referrals.

• Enhance adherence and psychosocial-support activities at sites, including the implementation of support

groups and the use of peer educators. ICAP will work with RIP+ (the national network of PLWHA

organizations) and local PLWHA organizations to replicate successful peer-education programs from other

countries (Rwanda, Swaziland, Ethiopia) to raise awareness about HIV testing and the availability of ARV

and palliative care services, to provide information and emotional support to palliative care patients, and to

conduct home visits to patients who are lost to follow-up.

• Work closely with SCMS and the Public Health Pharmacy (PSP) to ensure effective forecasting of needed

medications and test kits and to ensure timely delivery and management of stocks.

• Work with health districts to support the initiation of palliative care services at sites and to provide ongoing

supervision and quality-improvement monitoring.

• Support sites to implement patient record-keeping systems and databases and to summarize and analyze

data for routine reporting, using national tools. A data quality assurance system will be implemented, and

ICAP technical advisers will assist sites to analyze data regularly to assess program quality. ICAP will meet

regularly with the MOH to provide feedback on palliative care-related M&E tools and approaches to help

improve the national system of data collection and reporting.

• Support sites to provide HIV prevention counseling for HIV-positive individuals enrolled in programs.

• Enhance counseling of HIV-infected individuals to promote secondary prevention, enhance adherence to

care and treatment, provide psychosocial support, link patients to community resources, and identify

household members in need of testing, treatment, and care, including children in need of OVC services.

ICAP will also ensure that patients have access to nutritional assessment and counseling.

• Support sites to establish and strengthen links with community-based organizations to ensure community-

based patient support for home-based care, OVC services, adherence support, nutritional support, and

other services. ICAP will introduce a community resource mapping tool and support sites to develop formal

agreements and referral systems with relevant organizations.

At all sites, ICAP will provide - either through direct hire or by contracting with individuals or local

organizations - counselors dedicated to providing a comprehensive package of HIV prevention

interventions for all clients and effective referrals for persons living with HIV/AIDS and their children. ICAP

will engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients. A rule

of thumb is that per day, one counselor might provide HIV prevention interventions in small-group sessions

for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral services in

individual sessions for up to 10 HIV-positive clients.

Activity Narrative:

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will

include HIV prevention interventions and referral to community-based OVC and palliative care services to

address family and individual care needs. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Where possible, family-planning counseling and services will be provided to

patients and their partners through wraparound programming by other non-PEPFAR funded partners, and

condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their needs. With assistance from the National OVC

Care Program (PNOEV) and the PEPFAR in-country team, ICAP will ensure that community-based services

capable of meeting these needs are identified, and ICAP will be responsible for monitoring and reporting on

referrals according to a nationally standardized referral system.

ICAP will report to the USG strategic information team quarterly program results and ad hoc requested

program data. To participate in the building and strengthening of a single national M&E system, ICAP will

participate in quarterly SI meetings and will implement decisions taken during these meetings.

Noted April 21, 2008: ICAP will also provide subgrant funding to several subpartners formerly supported

through Alliance National Contre le SIDA.

ICAP-CU received Plus-up funds in 2007 to support the Ivorian MOH to expand the availability of a basic

package of HIV services at health facilities throughout the country in collaboration with other PEPFAR

partners including EGPAF, ACONDA, Alliance. By the end of COP07, ICAP-CU anticipates initiating VCT,

PMTCT, palliative care, TB/HIV and ART services at 5 sites, and conducting baseline assessments and

training at an additional 5.

In COP08, ICAP-CU will continue to support this package of services at all 10 sites covered in FY 07 and

expand to an additional 34, for a total of 44 HIV care and treatment sites. At all 44 sites, ICAP will ensure

that intensified TB case finding is consistently done among all the patients enrolled in HIV care and

treatment at enrollment and follow up visits, and that those who screen positive by symptoms are properly

managed, including provision of or referral for smear microscopy, chest x-ray, and TB culture according to

national guidelines. In addition, ICAP will ensure—either directly or in coordination with other implementing

partners (PEPFAR and GF)—that all (100%) TB suspects, either at the on-site TB clinic or at referring TB

treatment facilities (CAT and all CDTs in covered area) are tested for HIV and that those testing positive are

enrolled in care and treatment. Proven TB/HIV integration approaches and tools from ICAP-CU programs in

other countries, such as the simple TB screening tool developed in Rwanda, will be adapted for Côte

d'Ivoire in consultation with the PNLT. Similarly, a recently published ICAP monograph that highlights the

importance of TB screening will also be translated and adapted. ICAP-CU will also focus on promoting and

supporting processes that minimize nosocomial transmission of TB and that protect health care workers

from TB infection. ICAP's capacity building approach, focusing on district and facility-level systems

strengthening, and provider training and mentoring, ensures long term sustainability.

Interventions will include:

• Ensuring that minor renovations are completed taking into account fundamental infection control principles

that are appropriate for resource-lmited settings to prevent transmission of TB.

• Support for laboratories to conduct appropriate diagnostics for TB in the context of HIV co-infected

patients, ensuring that all the TB diagnostic sites have functional microscopes and that staff are competent

in smear microscopy.

• Provide intensive training and on-site mentoring on TB/HIV integration activities with focus on provider

initaited counseling and testing for all TB patients, routine TB screening among all patients enrolled in HIV

care and treatment, linkages and cross referrals between programs, and adherence and follow-up for co-

infected patients.

• Sites will be supported to introduce a standardized TB screening questionnaire for intensified TB case

finding in HIV-infected patients and to providing routine TB screening, prevention, care, and referrals for all

patients enrolled in care and treatment. This questionnaire is used routinely for TB screening in a number of

ICAP-supported care and treatment programs and has been demonstrated to be an effective way to identify

HIV infected adults at high risk for TB disease.

• Sites will be supported to implement provider initiated HIV testing and counseling (moving toward an opt-

out approach), prevention education, and referral for HIV care, if needed, for all TB patients. Staff at the TB

clinics will be trained in PITC using the training material developed by CDC/ WHO, which has been already

translated in French and adadpted.

• Implement systematic, preventive cotrimoxazole therapy for all (100%) HIV co-infected TB patients at TB

clinics.

• For all children under 5 and all infected children, a screening algorithm will be adapted to include history of

tuberculosis related symptoms, clinical indicators suggestive of tuberculosis, and history of TB contact

within and outside the household. The use of TST testing will be explored to establish the feasibility and

efficacy to determine TB infection status in this population. All children without evidence of active TB

disease (without clinical or historical evidence and with a negative TST response) will be considered for a 6

month course of Isoniazid prophylaxis against tuberculosis. IC sites will also provide INH-prophylaxis to

eligible HIV-infected patients as per the national guidelines.

• In addition to direct evaluation of TB risk in the child, the routine TB screening questionnaire mentioned

above will be administered to the adult caregivers of all children testing HIV positive. Most children are

exposed to TB through adult caregivers within the household and in child care settings. Adults with a

positive screening questionnaire will be referred for further evaluation. All pediatric household members will

be screened for HIV as well as TB.

• Ensure adherence with both TB and HIV treatment in order to achieve optimal patient outcomes. ICAP will

work with sites to develop innovative approaches to adherence support such as DOTs or using peer

educators to conduct patient follow up. ICAP will also work closely with NGOs and CBOs working with

Alliance to ensure community based support for TB and HIV patients.

• Ensure the implementation of data collection instruments developed by the national TB program (PNLT) to

monitor and evaluate HIV/TB screening, diagnosis, and treatment activities at all ICAP-CU supported sites.

The staff will be trained in the use of these tools.

• Ensure that linkages between HIV and TB clinics are established and strengthened at all ICAP-CU

supported sites.

The multidisciplinary care teams in each facility will include representation from the TB service. Mechanisms

to facilitate referral will be introduced, supportive supervision will be provided, and activities will be closely

assisted and monitored by ICAP-CU technical experts.

ICAP-Columbia University, a new PEPFAR partner in Cote d'Ivoire, received FY07 plus-up funds to help the

Ivorian Ministry of Health to expand provision of a basic package of HIV/AIDS services at health facilities in

the midwestern part of the country. By the end of FY07, ICAP anticipates initiating HIV counseling and

testing, PMTCT, palliative care, and ART services at five sites and conducting baseline assessments and

training at five more sites. In FY08, ICAP will support this package of services at all 10 FY07 sites and

expand to an additional 34 sites, for a total of 44 sites.

In addition to providing medical care and treatment, facility-based health services represent a critical

opportunity to impact client behavior through clear, authoritative health messages delivered in one-on-one

or small-group settings, as well as to connect clients effectively with community-based care services. To

use the opportunity to reduce risk behavior and thus HIV transmission, all PEPFAR Cote d'Ivoire ART and

PMTCT service providers will ensure that their package of services includes HIV prevention behavior-

change communication promoting risk reduction through abstinence, fidelity, correct and consistent condom

use, status disclosure, partner testing, and STI prevention and care targeting both HIV-positive and HIV-

negative clients. In addition, they will ensure that all HIV-positive clients are offered effective, monitored

referrals to community-based OVC and palliative-care services.

At its 44 PMTCT and 44 ART sites, ICAP will provide - through direct hire or, more commonly, by

contracting with individuals or local organizations - counselors dedicated to providing a comprehensive

package of HIV prevention interventions for all clients and effective referrals for persons living with

HIV/AIDS and their children.

ICAP will engage enough counselors to allow every site to provide this prevention and referral package to

all clients. A rule of thumb is that per day, one counselor might provide HIV prevention interventions in small

-group sessions for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral

services in individual sessions for up to 10 HIV-positive clients.

HIV-negative clients at PMTCT, CT, and TB sites:

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients at PMTCT, ART, TB, and CT sites:

At all clinical visits, clients who are HIV-positive will be referred (on an opt-out basis) to a counselor for

individual counseling that will include HIV prevention interventions and referral to community-based OVC

and palliative care services to address family and individual care needs now and in the future. Targeted HIV

prevention counseling will focus on risk reduction through abstinence, fidelity, correct and consistent

condom use, disclosure, testing of partners and children, and STI prevention and care. Where possible,

family-planning counseling and services will be provided to patients and their partners through wraparound

programming by other non- PEPFAR funded partners, and condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their individual needs. In these individual sessions,

the counselor will seek to obtain contact information (e.g. address, telephone number) for the client and

briefly assess the client's needs and resources. The counselor will provide the client with a brochure or

other illustrated materials showing what the palliative care and OVC care services might include, such as

clean water and bed nets for palliative care and educational, medical, nutritional, legal, and psychosocial

support for OVC. The counselor will then ask the client whether she or he would like to provide the names

of people in the household who might need referral to such services.

With assistance from the National OVC Care Program (PNOEV) and the PEPFAR in-country team, ICAP

will ensure that community-based services capable of meeting these needs are identified, and ICAP will be

responsible for monitoring and reporting on referrals according to a nationally standardized referral system.

Funding to support staffing and training of these counselors; training of physicians and nurses to refer

clients to the counselors; and adaptation and reproduction of job aids and prevention materials will be split

at approximately 50% Abstinence/Being faithful, 10% Condoms/Other Prevention, 10% Palliative Care, and

30% Orphans and Vulnerable Children. The reason for dividing the funding is to allow the program to

address an array of HIV prevention needs for HIV-positive and HIV-negative persons as well as to provide

effective linkages to OVC and palliative-care services for persons living with HIV. The program's effort will

reflect the funding and proportions noted here.

ICAP-CU received plus-up funds in FY07 to help the Ivorian Ministry of Health to expand the availability of a

basic package of HIV services at health facilities throughout the country. By the end of FY07, ICAP-CU

anticipates initiating CT, PMTCT, palliative care, and ART services at five sites and conducting baseline

assessments and training at an additional five sites. In FY08, ICAP-CU will support this package of services

at all 10 FY07 sites and expand to an additional 34, for a total of 44 sites.

Limited access to HIV counseling and testing remains a critical road block to the identification of HIV-

infected individuals and to ensuring their early access to HIV prevention, care, and ART, if eligible. ICAP will

ensure that counseling and testing are available at sites through regularly scheduled CT days, availability of

trained counselors, and the establishment of routine, provider-initiated testing throughout its supported

facilities.By February 2009, ICAP anticipates counseling and testing 27,750 individuals.

CT will become part of the continuum of HIV care for patients at each of these sites. ICAP's capacity-

building approach, focusing on district- and facility-level systems strengthening, and provider training and

mentoring, will help ensure long-term sustainability. Interventions will include:

• Support for the operations of CT services at 44 designated facilities. Once validated at the national level, a

new rapid-test algorithm will be introduced to improve turn-around time for test results and limit dependence

on laboratory staff, thus making point-of-services counseling and testing easier.

• Support for facilities to expand counseling and testing access and improve quality and linkages to care

and ART services.

• Provide training and on-site mentoring to at least 132 nurses, social workers, and counselors on CT.

Focus will be on strengthening providers' counseling skills, including for HIV prevention and couples

counseling.

• Promotion of the use of routine opt-out models in clinical settings such as ANC, TB, and STI clinics, and

for adult and pediatric inpatients and outpatients, to facilitate enrollment and entry into treatment programs.

ICAP will support sites to develop standard operating procedures related to routine testing within the facility

and will train appropriate staff.

• Development of tools, instruments, and databases to track HIV counseling and testing activities, including

linkages to HIV care and treatment.

• Support for facilities to establish strong linkages with PLWHA organizations, OVC services, faith-based

groups and community-based NGOs to reduce stigma surrounding HIV testing, promote HIV counseling

and testing, and ensure that those who test HIV-postive access care and treatment services.

• Work with health districts to support the initiation of CT services and ongoing supervision and quality

improvement.

• Work with SCMS and the Public Health Pharmcy (PSP) to ensure effective forcasting of test kits and to

ensure timely delivery and management of stock.

At all sites, ICAP will provide - either through direct hire or by contracting with individuals or local

organizations - counselors dedicated to providing a comprehensive package of HIV prevention

interventions for all clients and effective referrals for persons living with HIV/AIDS and their children. ICAP

will engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients. A rule

of thumb is that per day, one counselor might provide HIV prevention interventions in small-group sessions

for up to 80 HIV-negative clients or HIV prevention and OVC and palliative care referral services in

individual sessions for up to 10 HIV-positive clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for behavior-change

communication interventions, delivered individually or in small groups, focusing on risk reduction through

abstinence and fidelity, with correct and consistent condom use for those engaged in high-risk behavior, as

well as partner testing and STI prevention and care.

HIV-positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will

include HIV prevention interventions and referral to community-based OVC and palliative care services to

address family and individual care needs. Targeted HIV prevention counseling will focus on risk reduction

through abstinence, fidelity, correct and consistent condom use, disclosure, testing of partners and children,

and STI prevention and care. Where possible, family-planning counseling and services will be provided to

patients and their partners through wraparound programming by other non-PEPFAR funded partners, and

condoms will be provided free of charge.

In addition, all HIV-positive clients will be offered information about and referrals to specific community-

based OVC care and palliative care services tailored to their needs. With assistance from the National OVC

Care Program (PNOEV) and the PEPFAR in-country team, ICAP will ensure that community-based services

capable of meeting these needs are identified, and ICAP will be responsible for monitoring and reporting on

referrals according to a nationally standardized referral system.

Noted April 21, 2008: ICAP will also provide subgrant funding and technical assistance to several

subpartners formerly supported through Alliance National Contre la SIDA.

ICAP-CU, a new partner in Cote d'Ivoire, received plus-up funds in FY07 to help the Ministry of Health to

expand the availability of a basic package of HIV services at health facilities throughout the country. In

FY07, ICAP-CU anticipates initiating CT, PMTCT, palliative care, and ART services at five sites and

conducting baseline assessments and training at five more sites.

In FY08, ICAP-CU will support this package of services at all 10 FY07 sites and expand to an additional 34,

for a total of 44 sites. ICAP-CU anticipates initiating 4,750 people on ART, for a total of 5,000 patients on

ART by March 2009.

Adult ARV Services

In FY08, ICAP-CU will continue to support sites to provide high-quality ART services following national

guidelines. The focus will be on treating families - not just the individual - to better meet patient needs and

to assure better adherence and clinical outcomes. Sites will be supported to shift the organization of their

facility from a traditional episodic model of care to a chronic model of care for HIV patients, using a multi-

disciplinary team of providers. ICAP-CU will emphasize the involvement of PLWHA in programs through

peer-support interventions and strong linkages to community resources. ICAP-CU's capacity-building

approach, focusing on district- and facility-level systems strengthening and provider training and mentoring,

will help ensure long-term sustainability. Key activities and approaches will include:

• Support sites to recruit and retain staff for ARV service provision. ICAP-CU will work with districts and

facilities to identify staff needs and find creative solutions for augmenting staff. Providing the training,

resources, and tools needed for staff to provide quality ART services will help also motivate staff and

increase retention.

• Train 170 doctors, nurses, social workers, counselors, and outreach workers to provide ART, intensive on-

site mentoring during the initiation of services, and periodic follow-up training and mentoring thereafter.

• Support sites to identify HIV-positive patients by strengthening CT interventions, including routine provider-

initiated CT. ICAP-CU will support sites to publicize the availability of ART services in the communities they

serve.

• Support sites to develop patient-flow algorithms, patient-appointment systems, and protocols related to the

initiation of ART (e.g. number of pre- and post-ARV initiation appointments, standard ARV prescriptions,

etc.).

• Develop protocols and systems for clinical staging of HIV patients and establishing eligibility for ART using

national guidelines and clinical staging, when appropriate.

• Support the formation and functioning of multidisciplinary team meetings to discuss complicated cases and

coordinate individual patient care.

• Help sites to provide effective support to patients prior to ARV initiation, such as counseling about

disclosure, adherence, and peer support.

• Support sites to develop patient-tracking systems that will help to identify patients who have not returned

for pharmacy or other appointments. Protocols for patient home visits will be developed. ICAP-CU will

develop a program to train PLWHA as peer educators/counselors to support patients enrolled in ART

services and track patients who miss appointments or who are lost to follow-up. Peer educators will be

supervised by social workers or other staff.

• Ensure strong linkages within the facility and with community-based services. Referral mechanisms will be

developed between ART services and other services (inpatient and outpatient departments, CT, PMTCT,

TB, under-5 clinic, family planning). HIV testing will be routinely offered to all patients in these services. HIV

program management committees, including key staff representing various departments, will meet regularly

to coordinate services and cross-referrals.

• Support sites to establish/strengthen links with community-based organizations to ensure patient support

for home-based care, OVC services, adherence support, nutritional support, and other services. ICAP-CU

will introduce a community resource mapping tool and support sites to develop formal agreements and

referral systems with relevant organizations.

• Ensure availability of lab services for CD4 testing and to monitor drug toxicity. ICAP-CU plans to upgrade

all district hospital labs so they can provide CD4 testing for the entire district. ICAP-CU will support each

district to develop an effective sample transportation system to ensure that patients at the health center

receive CD4 results in a timely manner. Labs at all levels will have enhanced biochemistry and hematology

capacity.

• Work with SCMS and the Public Health Pharmacy (PSP) to support site pharmacies to establish systems

for ARV quantification, stock management, and patient appointments and to train pharmacists in counseling

patients about ART, including side effects and adherence. All ARV, OI drugs, and other commodities will be

procured by SCMS and distributed to sites via the PSP.

• Provide regular, supportive supervision, clinical updates, and refresher training to multidisciplinary care

teams and ART program managers, including the integration of M&E data into program planning and

improvement.

• Support sites to implement patient record-keeping systems and databases and to summarize and analyze

data for routine reporting using national tools. A data quality-assurance system will be implemented, and

ICAP-CU technical advisers will assist sites to analyze data regularly to assess program quality. ICAP-CU

will meet regularly with the MOH to provide feedback on ART-related M&E tools and approaches to help

improve the national system of data collection and reporting.

At all ART, PMTCT, and CT sites, ICAP-CU will provide - either through direct hire or by contracting with

individuals or local organizations - counselors dedicated to providing a comprehensive package of HIV

prevention interventions for all clients and effective referrals for PLWHA and their children. ICAP-CU will

engage enough counselors (funded in part through AB, Condoms and Other Prevention, OVC, and

palliative care funds) to allow every site to provide this prevention and referral package to all clients.

All clients who test HIV-negative will be referred (on an opt-out basis) to a counselor for BCC interventions

focusing on ABC methods of risk reduction, as well as partner testing and STI prevention and care. HIV-

positive clients will be referred (on an opt-out basis) to a counselor for individual counseling that will include

ABC prevention interventions (including disclosure, partner and family testing, and STI prevention and

care). Where possible, family-planning services will be provided through wraparound programming by non-

PEPFAR funded partners, and condoms will be provided free of charge. All HIV-positive clients will be

Activity Narrative: offered information about and referrals to specific community-based OVC care and palliative care services

tailored to their needs. ICAP-CU will ensure that community-based services capable of meeting these

needs are identified, and ICAP-CU will be responsible for monitoring and reporting on referrals according to

a nationally standardized referral system.

Pediatric ARV Services

ICAP-CU will ensure that at least 10% of HIV care and treatment patients enrolled at its 44 sites are infants

and children (at least 500 patients on ART by March 2009). ICAP-CU has championed the cause of care

and ART for pregnant women and children throughout the programs it supports. It will continue to adapt and

utilize these tested systems, tools, and procedures to achieve this goal. ICAP-CU has established a South

to South (S2S) Pediatric Training Center in Cape Town, where ICAP-CU-supported country teams have

received hands-on training and mentoring in pediatric care and treatment. Ivorian teams will be beneficiaries

of this resource.

Pediatric support will focus on increasing availability of infant HIV diagnostics, enhancing pediatric case

finding and referral, ensuring comprehensive care and treatment services for HIV-exposed infants and for

HIV-infected infants and children, and increasing access to pediatric ART. Emphasis will be placed on full

involvement of families. An ICAP-CU pediatric adviser will work closely with sites to provide focused training

and clinical mentoring for pediatric care and treatment. Interventions will include:

• Assess lab services for pediatric diagnostics and design capacity-building plans. This will include assuring

the availability of dried blood spot diagnosis by DNA PCR via specimen referral to the regional or national

reference laboratory level.

• Establish or strengthen HIV testing at entry points to pediatric services (inpatient wards, family-centered

care programs, CT programs, adult ART clinics, under-5 clinics).

• Strengthen referral mechanisms between ART clinic and entry points to pediatric services.

• Assess staff capacity for pediatric ART and provide targeted supplementary training.

• Strengthen care services (including staging, cotrimoxazole prophylaxis, nutrition and growth monitoring,

parental counseling, social and adherence support) for all HIV-exposed and HIV-infected children.

• Assess feasibility of co-located services and/or coordinated appointment scheduling for HIV-infected

women and their children.

• Work closely with SCMS and PSP to ensure a seamless supply of pediatric ARV and OI drug formularies.

• Establish pediatric and family support groups.

• Establish or strengthen links to community-based services for infants and children, including nutritonal

support and OVC services.

ICAP-Columbia University, a new PEPFAR partner in Cote d'Ivoire, received FY07 plus-up funds to help the

Ivorian Ministry of Health to expand provision of a basic package of HIV/AIDS services at health facilities in

the midwestern part of the country. By the end of FY07, ICAP anticipates initiating HIV counseling and

testing, PMTCT, palliative care, and ART services, with integrated HIV prevention activities, at five sites and

conducting baseline assessments and training at five more sites. In FY08, ICAP will support this package of

services at all 10 FY07 sites and expand to an additional 34 sites, for a total of 44 sites.

In the past three years of implementing large-scale HIV care and treatment programs in other African

countries, ICAP has developed expertise in establishing effective data-management systems in low-

resource settings. The overarching goal of the SI component of ICAP's program is to develop and conduct

high-quality, timely, and sustainable monitoring and evaluation of project-supported activities for program

evaluation and improvement. This is a collaborative effort with local, national, and international partners to

routinely collect, analyze, and disseminate data to assess program quality and program impact within and

across sites and countries.

In Côte d'Ivoire, ICAP will implement the nationally approved M&E system and tools, including harmonized

patient-monitoring tools, and will participate in EP and national committees and work groups to review and

revise M&E tools. ICAP will establish an M&E team to support accurate site-level data collection and

reporting, as well as aggregate reporting of required indicators, to the MOH and EP using existing

harmonized patient-monitoring tools. ICAP technical and site staff will use available data to assess the

quality of care and develop and implement quality-improvement activities. ICAP's New York-based M&E

team will provide technical support to ensure effective implementation of data collection and reporting

systems at sites.

As project activities were starting in the fourth quarter of FY07, ICAP was hiring and orienting key staff in

Abidjan, recruiting and training data clerks at new sites, implementing the national patient-monitoring and

M&E tools at new sites, and electronically capturing patient-level data for reporting, monitoring, and

evaluation.

In FY08, ICAP will fund activities to support M&E data collection, management, use, and transmission at the

site level as well as data integration, analysis, use, and reporting at the country headquarters level. The

M&E country team based in Abidjan, reinforced by technical assistance from ICAP headquarters, will

participate in the building and strengthening of a unified national M&E system. Specifically, ICAP will

implement the following activities:

ICAP Country Team Activities

In collaboration with the USG country team, national counterparts, and other PEPFAR partners, EGPAF SI

officers will:

1) Participate in adapting country data-collection tools (paper and electronic).

2) Provide ongoing technical support and training to data clerks.

3) Train EGPAF multidisciplinary care teams on how to use program data to assess the quality of care at

their sites.

4) Provide semi-annual and annual program results and ad hoc data sets as requested by the USG team.

5) Participate in quarterly SI meetings organized by the USG strategic information branch and implement

decisions made during these meetings.

6) Submit articles to peer-review journals.

Site- and District-Level Activities

ICAP will:

1) Hire, orient, and continually train and supervise site-level data clerks as necessary.

2) Provide SI-related materials to each site, including computer hardware and software, printers, registers,

forms, and Internet connectivity.

3) Send field staff to specific workshops, conferences, or classes that bolster their technical capacities.

4) Support the SI capacity development of all personnel within the health facilities hosting ICAP activities.

Strengthening of National SI Activities

In support of the national SI system, ICAP will:

1) Provide training and strong support to district teams responsible for data recording and transfer,

electronic recording and processing, and reports editing. District teams will prepare monthly reports that

include information related to all aspects (quantitative and qualitative) of ICAP's program. Reports will be

sent to the regional level and to the National HIV/AIDS Care and Treatment Program (PNPEC) to feed into

national data-collection efforts.

2) Develop and execute a data-quality improvement plan with technical assistance from external contractors

and in close collaboration with the CDC/Project RETRO-CI SI team and district data managers.

3) Collaborate with the PNPEC and other partners to use a unique patient identifier to follow patients

through time and space.

4) Feed commodities data into the national data-collection system for drug and supply-chain management.

The patient-management system being used at all sites will be interfaced with the Partnership for Supply

Chain Management system, which will monitor all care and treatment commodities data for EP programs in

Cote d'Ivoire.

5) Participate in ongoing national efforts to maintain and improve a harmonized national longitudinal HIV-

positive patient monitoring system.

To promote sustainability, the hiring of staff will be conducted in close collaboration with the MOH and other

government decentralized entities (mayors, general councils).