In April 2009 reprogramming, funds are being allocated to FHI under the new CDC TA mechanism for HIV

prevention and care activities targeting MSM.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $4,550,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Prevention of biomedical transmission of HIV remains a high priority for Côte d'Ivoire (CI) and the PEPFAR CI team in 2009.

Despite continuing challenges due to the political environment, which have limited expansion of blood-safety and injection-safety

activities, the Ministry of Health and Public Hygiene (MSHP) has made an increasing commitment to strengthening service quality

and national ownership by building local capacity and encouraging sustainable national systems. In the area of blood safety, the

MSHP's National Blood Transfusion Service (NBTS) will continue, with PEPFAR support, to ensure an adequate and safe supply

of blood while increasing its autonomy by assuming responsibility for directly contracting all needed technical and administrative

assistance, previously provided by an international Track 1 partner. In the area of injection safety, the MSHP will take over the

lead on injection safety and medical waste management from John Snow Inc. (JSI)

Blood Safety

The NBTS is responsible for recruiting and retaining blood donors and for collecting, testing, processing, storing, and distributing

blood nationwide. Its strategy, based on WHO recommendations for the development of centralized national blood programs,

focuses on ensuring an adequate and safe supply of blood for transfusion through the recruitment of low-risk, voluntary, non-

remunerated donors; comprehensive laboratory screening for transfusion-transmissible infections (TTI) on all donated blood;

strengthening of policies and infrastructure (e.g. maintaining an effective cold chain); and training prescribers on the appropriate

use of blood products.

PEPFAR support has helped improve the NBTS' ability to meet the national demand for blood. It is estimated that Côte d'Ivoire

needs to collect 170,000 units of whole blood per year (based on 1% of the total population) to have an adequate supply of blood

and blood products. Since 2003, the NBTS has made substantial progress in increasing the number of whole blood units collected

each year. By 2007, annual whole blood collections had increased by 36%, to 92,000 units. During the same period, the NBTS

strengthened its capacity to fractionate whole blood into blood products and to collect blood directly into pediatric-size bags. In

conjunction with the development of national guidelines and training on the appropriate use of blood and blood products, these

improvements further increased the availability of blood products nationwide. In 2006, more than 121,000 units of whole blood and

blood products were produced and derived from 86,000 units of whole blood collected.

The safety of collected blood has been improved by advances in the NBTS laboratory system; testing at the Abidjan laboratory

has been mostly automated. HIV prevalence among donated units has declined marginally since 2003, while upward trends in the

prevalence of hepatitis B (HBV), hepatitis C (HCV), and syphilis have been observed. In 2005, prevalence rates among repeat

donors were 0.3% (HIV), 0.4% (syphilis), and 1.2% (HBV and HCV). By September 2007, the prevalence of syphilis, HBV, and

HCV had increased (to 2.3%, 0.8%, and 1.8%, respectively), but the prevalence of HIV among repeat donors had decreased to

0.1% (compared to a 1.2% HIV prevalence among first-time donors). Only 6.7% of donors return to receive their test results. For

donors who test seropositive for HIV, the NBTS has established an on-site clinic that serves as a national reference center and

provides follow-up care.

All blood units are collected from voluntary, non-remunerated donors, 41.4% of whom are regular donors. To increase the donor

pool, the NBTS implements community-mobilization activities, such as establishing donor groups in schools, churches, and in the

workplace. Rigorous pre-screening questionnaires serve to narrow the donor pool to the most low-risk donors. Information from a

knowledge, attitudes, and practices (KAP) survey about blood donation will help the NBTS to recruit and retain donors with a

lower behavioral risk profile for sexually transmitted infections.

The NBTS distributes blood products through a regional network and through hospital blood banks in an effort to decentralize

collection, storage, testing, and distribution and thus reduce logistical barriers to access. Côte d'Ivoire's political crisis created

significant challenges to scale-up of blood-related services, but the NBTS reopened two collection and transfusion centers in the

North (Bouake, Korhogo) with PEPFAR support in 2007, greatly increasing access to services in the formerly rebel-occupied

region. Nine blood transfusion centers and 41 blood banks were renovated in 2008 with PEPFAR support. Three new satellite

collection sites have been opened since 2006, and two blood collection vans are in service. More than 200 hospitals nationwide

are performing transfusions with blood from NBTS blood centers and blood banks.

The NBTS conducts trainings to reinforce the capacities of local staff and improve the national blood management system. These

trainings have included instruction in the operation and maintenance of Progesa and E-Progesa blood-tracking software, blood

collection and preparation procedures, monitoring and evaluation (M&E), blood donor screening and selection processes, and the

appropriate use of blood products for prescribers.

Program monitoring is ongoing through routine M&E activities and supervision visits. Quality assurance measures such as

technical audits and inter-laboratory control systems continue to be implemented to ensure consistent and high-quality service

delivery.

PEPFAR supports blood safety in Côte d'Ivoire through CDC cooperative agreements with the NBTS and Social and Scientific

Systems (SSS), a Track 1 technical assistance provider.

FY09 Priorities in Blood Safety

Improving donor recruitment and mobilization: New strategies based on the results of the KAP study among current and potential

blood donors will be developed to strengthen outreach activities and encourage repeat donations from low-risk donors so that the

NBTS can reach its target of 160,000 units donated in FY09. Partnerships with donor clubs and associations will be strengthened

to increase the pool of eligible donors and conduct community-mobilization activities. Radio and TV spots informing the public

about blood donation will contribute to recruitment efforts.

Increasing access through renovation and rehabilitation: Renovation of blood-transfusion centers in Abengourou, Bondoukou, and

Abidjan, as well as the opening of new collection sites in Ferkessedougou, Bonoua, and Adzopé, will contribute to increasing

access to donation and transfusion. These centers will be equipped with the appropriate blood-bank software and network system

to enable communication and tracking among blood banks. The NBTS will also restore and equip 12 hospital blood banks in FY09

in order to improve clinical transfusion.

Testing and quality control: The NBTS will continue to strengthen its laboratory quality control management systems. Quality

assurance procedures will continue to be implemented in hospital blood banks. A national hemovigilance system will be finalized

and implemented to better track the use of transfused blood products such as red cell concentrates and other blood component

preparations.

Technical assistance: Since FY 2004, the NBTS has worked in close collaboration with Track 1 technical assistance provider

SSS. Starting in FY09, SSS will be phased out, and capacities will be transferred to the NBTS, which will contract for technical

and administrative assistance as needed. Among others, the NBTS will partner with the Belgian Red Cross and the NGO

Transfusion and Development to improve the blood-management system in Côte d'Ivoire.

Training: Training shortfalls in FY08 will be addressed in FY09 through more rigorous training scheduling. Specialized training in

serology and immunohematology, quality assurance, and hemovigilance will be organized for senior staff. Trainings will also be

conducted on topics such as E-Progesa software utilization, M&E, and best practices in blood collection. Physicians will be

provided with training in appropriate and rational uses of blood. In-service training for data managers and M&E staff will be

ongoing.

Policy and guidelines: The NBTS will disseminate policy and guideline documents on the prescription of blood products for

hemorrhages to allow for more standardized approaches to blood utilization in clinical settings. Policy documents on the legal

framework of blood transfusion in Côte d'Ivoire will be developed to reinforce the legal position of NBTS within the Ivorian health-

care system.

Sustainability: In addition to the continued transfer of capacity and ownership to the NBTS, the partner has developed a

sustainability working group that will work to develop long-term strategic plans to reinforce local capacity and increase government

engagement. The strategy will document the phased integration of the national blood safety program in the MSHP budget, with

diminishing PEPFAR inputs over the next five years. It will include an analysis of the costs associated with producing a unit of

blood.

Injection Safety

In 2004, PEPFAR awarded JSI a five-year cooperative agreement under the MMIS project to provide a rapid response to prevent

the medical transmission of HIV and other blood-borne infections by improving the safety of medical injections in health facilities.

The project was funded to provide capacity building, logistics management, behavior change communication (BCC), waste

management, and monitoring and evaluation (M&E). The project has made significant strides in covering 45 districts nationwide

with injection safety and medical waste management interventions, including training health care workers and waste handlers;

procuring auto-disable syringes, retractable syringes, and safety boxes; disseminating radio and TV spots for BCC; updating the

National Waste Management Strategic Plan; conducting supervision visits with district supervisors; rehabilitating incinerators; and

advocating for incinerator construction.

With the JSI/MMIS agreement ending in September 2009, and to promote a smooth transition, there is a need to transfer capacity

and ownership to Ivoirian entities to strengthen the national commitment to injection safety, reinforce national and local capacity,

and encourage program sustainability. With FY09 funding, the MSHP will take the initiative in spearheading the national injection

safety program. While the JSI/MMIS project transitions out, the MSHP will establish an injection safety team, housed at the Public

Hygiene Regulation Department (DRHP), to ensure the availability of safe injection supplies, conduct injection safety training,

reduce nosocomial infections of HIV due to needle-stick injuries, and work toward establishing a standardized national system of

medical waste management.

FY09 Priorities in Injection Safety

Training: JSI/MMIS will continue to conduct trainings in injection safety and waste management, focusing on a pool of district-level

trainers to promote sustainability and maintain institutional memory amidst high turnover of health care workers. JSI/MMIS will

collaborate with medical training institutes to integrate injection safety concepts into medical curricula. After transition to the MSHP

injection safety team, MSHP will continue to develop these pre-service training modules, along with in-service training modules, in

close collaboration with the National Institute of Training for Healthcare Workers (INFAS), to increase safe injection and improve

phlebotomy practices.

Commodities procurement: JSI/MMIS will release all stocks of injection safety commodities to the districts through the National

Public Health Pharmacy (PSP) while maintaining remote monitoring of both the distribution and management of these stocks.

Because the PSP has a 1.5-year supply of syringes in stock from JSI, the Partnership for Supply Chain Management Systems

(SCMS) will procure only safety boxes in FY09. Although funds for commodities procurement will be provided directly to SCMS,

the MOH will be heavily involved in determining supply volume and needs in the field. Collaboration with the PSP will ensure

district-level procurements, help in tracking stocks and responding to demands from local hospitals and health centers for safe-

injection supplies, and help manage the large stock of syringes.

BCC: JSI/MMIS will continue to reproduce and distribute existing BCC materials and job aids to reinforce injection safety

messages. A nationwide multimedia campaign will focus on changing community attitudes toward injections, aiming to reduce the

demand for unnecessary injections. Based on these models, the MSHP will develop a BCC strategy for health centers and the

community, including information sessions for prescribers and community-outreach activities for the public.

Waste management: JSI/MMIS will focus on supporting several health districts in the repair and rehabilitation of incinerators.

Results of a pilot intervention on medical waste segregation conducted in Port-Bouet and Alépé will be used to develop similar

interventions at the University Hospital Center at Treichville and other health centers. The MSHP will continue to lead the

collaboration of partners involved in national medical waste management, including the Ministry of Environment, WHO, World

Bank, and GAVI. Based on pre-identified needs, incinerators will be constructed, repaired, and maintained with the technical and

financial assistance of other key actors. The MSHP will also provide training in safe waste management.

Advocacy: With the evolution of the MSHP injection safety team, advocacy activities in favor of hepatitis B vaccination for health

care workers as prevention against contamination during accidental needle sticks will be conducted. In addition, the MSHP will

advocate for the availability of post-exposure prophylaxis (PEP) in health centers and hospitals. With FY09 funding, the MSHP will

work toward developing a national protocol for the reporting of needle-stick injuries among health care workers to help ensure that

exposed workers are provided with appropriate treatment and follow-up.

M&E: Injection safety task force meetings will focus on assessing transition strategies and reflections on the way forward.

JSI/MMIS will continue ongoing M&E activities and waste management working group meetings. After the transition, MSHP will

conduct district supervision visits to observe adherence to correct injection safety and medical waste management practices and

will lead national working group meetings to establish strategies for injection safety and waste management.

Table 3.3.04: