PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2007 2008 2009
Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has received USG funds to assist the
Ministry of Health (MOH) in supporting and expanding quality PMTCT programs while building on and
complementing other programs supported by PEPFAR, the Global Fund, UNICEF, and others. EGPAF
works to implement a family-centered approach in delivering care and treatment. In FY09 its PMTCT
program will support 235 sites and serve 162,000 women who will be offered HIV counseling, testing and
will receive their test results.
In FY08 the program has had some notable successes:
• Provision of technical and financial assistance to update and disseminate the national PMTCT policy and
guidelines, including combination ARV prophylaxis and routine HIV counseling and testing (CT), and
support for the development of new training tools and materials.
• Successful introduction of a series of innovative approaches, including a district approach to broaden the
program's reach, dried blood spot (DBS) techniques for early infant diagnosis using DNA PCR, provider-
initiated "opt-out" HIV testing at most sites, rapid testing in labor and delivery, and use of complex ARV
prophylaxis regimens, including assessment of ART eligibility for pregnant women and provision of ART to
eligible clients.
• Improvement of the quality of PMTCT services at all sites receiving direct support from EGPAF, achieving
better uptake at every level of the PMTCT cascade (CT, results, prophylaxis, and follow-up). EGPAF and its
partners have also improved follow-up and strengthened referrals to care for HIV-positive mothers and
infants.
• Strengthened PMTCT monitoring and evaluation systems at the national, district, and site levels, in
collaboration with government and other key partners.
• Strengthened nutritional counseling by health workers for antenatal and postpartum HIV-infected women,
including counseling on breastfeeding cessation and culturally appropriate replacement foods at 15
demonstration sites, with support from EGPAF's sub-partner PATH, Helen Keller International/Abidjan and
the national HIV nutrition technical working group.
• Use of performance-based contracting to support PMTCT programs, with development of M&E tools to
collect patient data, monitor program quality, and ensure correct reimbursement to sites for services
performed.
• Increased involvement in PMTCT program implementation by national health-professional associations
(pediatrics, obstetrics/gynecology, and midwifery), the MOH HIV care and reproductive-health programs,
and district health teams to improve ownership, training, and supervision of integrated PMTCT services by
key stakeholders.
In FY09 EGPAF will continue expansion based on a series of principles centered on a more "public health"
approach to PMTCT expansion, including:
• Improved integration of PMTCT into existing ANC programs
- The inclusion of the National Reproductive Health Program (PNSR) as well as the National HIV/AIDS
Care and Treatment Program (PNPEC) in the development of the program
- The diffusion of joint directives from both programs to lead PMTCT programming
- Including PMTCT in the definition of the "minimum package" of ANC activities
• Extensive health-promotion activities to increase PMTCT uptake within ANC and maternity programs
• Expansion of the district approach that has proved successful in Abengourou
• Development of regional training teams to support district-led implementation
• Increased reliance on partnerships with NGOs, faith-based organizations, and the private sector to
promote community linkages with other maternal child health and HIV/AIDS programs, such as OVC
programs.
• Nearly universal opt-out testing
• Rapid expansion of whole blood finger-prick HIV rapid diagnostics to replace the venous blood draws and
centrifugation of specimens to obtain plasma currently required for HIV testing.
In FY09 the successful interventions described at the beginning of this section will be retained through
planned scale-up and expansion of services. Through the district approach, EGPAF will cover at least 80%
of the health facilities in each health district. The district health team will take the lead in site assessments,
activity implementation, and supervision. EGPAF will provide technical assistance and logistical support.
At all PMTCT, ART, and CT sites, EGPAF 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. EGPAF 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. EGPAF will ensure that community-based services
capable of meeting these needs are identified, and EGPAF will be responsible for monitoring and reporting
on referrals according to a nationally standardized referral system.
EGPAF will continue to work with the MOH, UNICEF, UNFPA, JHPIEGO, ICAP-Columbia University,
ACONDA, and other partners to refine overall national policies, guidelines, and plans for scaling up PMTCT
and associated services in strategic geographic areas while emphasizing some of the newer approaches,
Activity Narrative: particularly finger-prick diagnostics and opt-out testing. Quality-assurance programs for PMTCT activities
will be coordinated closely with the PEPFAR-funded partner URC (University Research Corporation).
EGPAF will also continue to coordinate with SCMS and the USG for procurement of all HIV-related
commodities to avoid stock-outs. Regarding laboratory services, EGAPF will rely on CDC/Projet RETRO-CI,
the national network of laboratories, CDC International Laboratory Coalition partners, and other relevant
national or international reference labs for support of PMTCT services and quality control.
EGPAF will continue to work with community-based partners such as Alliance CI, ANADER, and CARE
International to improve linkages with social services, community mobilization and psychosocial support,
and OVC programs through engagement of community workers and PLWHA. NGOs and CBOs will be
identified in each health district in collaboration with RIP+ (network of PLWHA organizations) to perform
community-based activities around PMTCT sites.
For nutrition of children born to HIV positive mothers and care of malnutrition EGPAF will continue to
strengthen infant feeding, nutrition support and counseling in collaboration with the national nutrition
program and with other PEPFAR implementing partners with expertise in this area such as PATH, FANTA,
HKI, and IBFAN-CI. Measure/JSI for M&E; Helen Keller International Foundation, and the World Food
Program for nutritional support.
EGPAF will continue to provide support to the national reproductive health program to solidify the linkages
between reproductive-health services and PMTCT. Technical support from JHU/CCP will continue for the
development or adaptation of job aids, client information, and other materials. EGPAF's continuum-of-care
approach for bridging PMTCT and ART activities is described in the accompanying ART narrative but
applies equally to PMTCT and will be applied at all PMTCT sites. EGPAF will collaborate with the MOH and
the USG team in PHE activities.
EGPAF plans to conduct evaluations of ANC attendance and the feasibility of cervical dysplasia screening
among HIV-positive at PMTCT sites.
EGPAF's M&E team will report to the USG strategic information team quarterly program results and ad hoc
requested program data. To help build a unified national M&E system, EGPAF will participate in quarterly SI
meetings and will implement decisions taken during these meetings.
Sustainability
In FY08 EGPAF demonstrated that improved capacity, coordination, and engagement of the district health
team through a district approach enabled rapid scale-up of services in Abengourou and Agnibilekro districts.
Though a funding mechanism by which funds can be appropriated directly to a health district has not been
established, EGPAF plans to expand the district approach in FY09 to 14 districts. EGPAF will provide: 1)
basic infrastructure support such as conference space for district meetings and trainings, basic equipment
and minor renovations to offices, pharmacies, laboratories and health facilities; 2) training of trainers for
regional and/or district teams to conduct refresher trainings in districts; 3) laboratory equipment and
facilitation of a lab network and logistic arrangements for the transport of samples to referral labs when not
on site; 4) consumables and lab reagents; 5) transportation in the form of vehicle(s) for high performing
districts; 6) supervision and coaching of health care workers; 7) reinforced management capacity through
action plan and budget development as well as national and international courses. Over time, once the
district team takes the lead in planning and implementing activities, EGPAF's role will be reduced to
technical assistance.
In-service training of health care workers is a continuous process due to transfer and attrition. Off-site
training is expensive and contributes to human resource shortages. The next generation of health care
workers must be trained pre-service. Currently practical clinical training occurs at urban tertiary care centers
not representative of the majority of public sector settings in which providers in Cote d'Ivoire will work. In
FY08 EGPAF initiated a program with two national training schools to provide practical pre-service training
for medical and social work students in HIV, malaria and TB. Nineteen medical and 50 social work students
were given theoretical training and completed a six month internship at an EGPAF-supported site. In FY09,
EGPAF will expand both of these programs to include 50 additional medical and 100 social work students.
Based on the success of the program, in FY09 EGPAF will sign agreements with the pharmacy training
program for placements for 25 students in drug supply chain management and the nurse midwife training
program for placements of 25 midwives in PMTCT programs.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15110
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15110 4591.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $1,800,000
Disease Control & Pediatric AIDS Expansion
Prevention Foundation (country supp)
10039 4591.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $2,000,000
4591 4591.06 U.S. Agency for Elizabeth Glaser 3388 437.06 EGPAF- Call to $1,815,000
International Pediatric AIDS Action Project
Development Foundation (PMTCT)
Emphasis Areas
Construction/Renovation
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Malaria (PMI)
* TB
Military Populations
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $250,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $300,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $100,000
Economic Strengthening
Education
Water
Table 3.3.01:
With funds reprogrammed in April 2009, EGPAF will also support additional subpartners to conduct AB
prevention activities. EGPAF's combined AB funding will support AB prevention outreach to 20,000 people
by September 2009 and to an additional 34,888 people by September 2010.
works to implement a family-centered approach in delivering care and treatment.
Behavioral studies done in 2002 and 2004 show poor knowledge of STIs, high risk behavior through
multiple sexual partnerships, and low condom use among youth.
Students and some out-of-school youth are able to attend the school and university health services system
(SSSU). In FY09 EGPAF will ensure that youth who attend the SSSU centers will benefit from behavior
change communication (BCC) messages around compassion for people living with HIV, abstinence and
being faithful provided during individual counseling sessions, in small groups during consultations or in their
place of study or work (schools, hair salons, transport centers or at home). BCC messages will be provided
by trained peers or counselors. EGPAF will collaborate with the Ministry of Education (DMOSS) and school
health services program (PNSSU). Five SSSU in urban areas will be targeted to maximize the reach of AB
messages.
Blood donors presenting at a blood transfusion center or identified during mobile blood transfusion will
receive BCC messages on HIV prevention from a community counselor attached to the blood transfusion
services. HIV prevention messages will be provided on an individual and group setting. In addition to
abstinence, partner reduction, and use of condoms messages, blood donors will be encouraged to be
tested along with their partners and to learn about HIV care and treatment and treatment for STIs.
To achieve results in AB, EGPAF will also work with UNADSCI (national blood donors association), AJPDS,
N'Zraman, Fondation Djigui, and the Association of Christian Churches.The role of the PNSSU will include
training of caregivers to run AB programs among pupils and students. UNADSCI, under the supervision of
CNTS, will be in charge of AB activities among blood donors. Quarterly meetings organized by PNSSU and
UNADSCI will allow EGPAF to measure progresses. In addition, frequent supervision will be undertaken
with the PNSSU. Before and after surveys will be conducted on knowledge, aptitudes and practices of
young people at 3 SSSU as well as among other blood donors to follow trends in high-risk behavior within
the EGPAF/CNTS/PNSSU program.
EGPAF activities will complement activities of other PEPFAR partners in this domain, such as Alliance Cote
d'Ivoire and ANADER, with whom EGPAF collaborates closely.
Taking advantage of the opportunity to reduce risk behavior and thus HIV transmission, all ART and
PMTCT service providers will ensure that their package of services includes HIV prevention behavior-
change communication messaging 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.
In addition, all HIV-positive clients will be offered information about and referrals to specific community-
based OVC care and HIV care and support services tailored to their individual needs. EGPAF will ensure
that community-based services capable of meeting these needs are identified and will be responsible for
monitoring and reporting on referrals.
EGPAF will engage enough counselors to allow every site to provide this prevention and referral package to
all clients. As a rule of thumb one counselor is expected to 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: program for placements for 25 students in drug supply chain management and the nurse midwife training
Continuing Activity: 16524
16524 16524.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $440,000
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $25,000
Estimated amount of funding that is planned for Education $100,000
Table 3.3.02:
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 particularly significant effect on controlling the spread of HIV infection.
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.
According to the 2005 HIV Indicators Survey, only 12% of women and 30% of men reported having used a
condom during their last ‘high risk' sexual encounter.
HIV prevention using condoms is intended to reduce high risk sexual interactions that occur without correct
and consistent condom use. To achieve this objective, it is necessary to promote both male and female
condoms: 1) at sites through community counselors coordinated via RIP+; and 2) in communities via
community health workers and through organizations such as COSCI and other national networks like
ARSIP. Two community counselors will be assigned per EGPAF care and treatment site. The counselors
will work closely with the social worker on site.
On site, providers will be educated to offer a prevention for positives package. During every individual and
group counseling session, counselors will address risky sexual behavior and discuss HIV prevention
strategies using abstinence, being faithful and condom use. Counselors will organize support groups of 10-
20 HIV-positive persons and lead demonstrations related to correct condom use.
The number of individuals reached through community outreach has been revised to be more realistic-
12,500 in FY09, rather than 105,000 as was proposed in FY08.
Facility-based health services represent a critical opportunity to impact patient 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 risky sexual 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 messaging 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.
all clients. As a rule of thumb, one counselor will be expected to 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.
Activity Narrative: basic infrastructure support such as conference space for district meetings and trainings, basic equipment
Continuing Activity: 16771
16771 16771.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $50,000
Table 3.3.03:
Ministry of Health (MOH) in supporting and expanding quality HIV/AIDS prevention, care, and treatment
programs while building on and complementing other programs supported by PEPFAR, the Global Fund,
UNICEF, and others. EGPAF works to implement a family-centered approach in delivering HIV services.
To strengthen EGPAF's adult care and support program in FY09, RIP+ (the Ivoirian network of PLWHA
organizations) will coordinate the activities of PLWAs as community counselors to take an active part in the
care for HIV-positive persons at all EGPAF-supported sites.
In addition to partnering with RIP+, EGPAF will sign agreements in FY09 with additional local organizations
to support care and support for people living with HIV. These organizations include: Femmes Actives,
Solidarite Plus, ACID, Fraternite, M'bade Victoire, Tous Pour le Taupke, Manne du Jour, Manasse et
Sidalerte. EGPAF will continue to expand the role of these groups in FY09 in the area of patient education
and ART adherence.
One component of these community group activities will be demand generation. EGPAF will work with these
organizations to promote HIV services (VCT, PMTCT, HIV care and treatment and TB) through local radio,
campaigns, open houses and other community strategies. Organization members will be trained in a
participatory, adult learning approach to initiating dialogue in communities, using communication materials
developed by PSI, such as the "boat game", drawing games, debate, scenarios and the risk game.
EGPAF will work with the above local organizations as well as local radio stations to promote VCT, PMTCT,
care and treatment and TB services. These promotional campaigns will be timed prior to quarterly open
houses organized at the larger sites in coordination with district, health facility and local leadership to
ensure success. The local radios for new partnerships with EGPAF in FY09 are located in the districts of
Danane, Bouake, Korhogo, Abobo, Koumassi and Treichville. EGPAF has already worked with ten other
local radios in San Pedro, Bongouanou, Abengourou, Agnibilekro, Ferkessedougou, Adzope, Koumassi,
Cocody, Port Bouet and Adjame Plateau. EGPAF will provide radio stations with promotional materials
(radio spots, posters, brochures and pamphlets) developed with JHU/CCP.
Non-medical health personnel in Cote d'Ivoire should play a larger role in the care of persons living with
HIV. Community counselors and social workers require additional training to enable some task shifting, with
an anticipated outcome of improved patient adherence in the treatment of OIs and related to ARV
treatment.
Another new initiative this year is the provision of "Hygiene Kits" consisting of insecticide treated bednets,
condoms and water filtration systems to HIV-positive persons as part of the prevention for positives
package. This hygiene kit has been distributed by PSI among uniformed services. Hygiene kits will be
provided by counselors or social workers, stored at pharmacies on site to monitor their distribution.
In previous years, EGPAF requests for HIV care and support funding have been relatively small and have
served to fund activities not covered in the ARV Treatment program area. As a result, care and support for
patients enrolled in HIV care but not yet eligible for ART has been somewhat short-changed, and program
results show that the ART program is not enrolling as many HIV-positive, non-treatment-eligible patients as
one would expect to see. EGPAF's introduction of performance-based contracting to support care and
treatment services are likely to change this distribution as sites realize that they can receive significant
program income from enrolling and closely following non-treatment-eligible patients.
The benefits of keeping close track of HIV-positive patients with high CD4 counts are significant, as early
initiation of ART has been demonstrated to greatly improve treatment outcomes. For FY09, EGPAF
proposes that the bulk of the funding for palliative care be used to support HIV+ patients enrolled in care but
not yet eligible for ART. These patients will be scheduled for quarterly check-ups, receive CD4 tests twice a
year, and be encouraged to come in for all significant illness episodes free of charge. They will receive
routine cotrimoxazole prophylaxis and nutrition assessment and counseling, which have been shown to
delay the need for treatment initiation. All TB/HIV co-infected patients and all pregnant women not yet
eligible for ART from PMTCT will receive the same package. At least 10% of enrolled patients will be
children, who will receive pediatric formulations of cotrimoxazole. Well-functioning referrals and counter-
referrals will be established with PEPFAR-funded OVC partners for testing and care.
While advocating and working for a consensus on a standardized affordable package of care to be available
across the health system, EGPAF has actively participated in efforts led by the MOH palliative care task
force to develop a national palliative-care policy along with a list of essential OI drugs adapted to different
health-care and community settings and a set of training curricula.
Altogether, FY09-funded activities are expected to provide care and support for 93,000 adults. Specific
activities to be supported with FY09 funding include:
• Reinforce partnership with RIP+ (network of PLWHA organizations) to empower nascent PLWHA support
groups in the interior of the country
• Contract with ASAPSU or a partner TBD to reinforce and expand food distribution as part of wraparound
activities
• Develop a positive-prevention package for clinical settings that also addresses family planning, disclosure,
and speaking to adolescents about their HIV status and lifelong treatment.
• Reinforce the partnership with Helen Keller International to couple food supplementation to income-
generating activities with WFP support. Greater involvement of PATH in the training of community support
groups or caregivers will complement this activity.
• Continue to assist in the development and dissemination of palliative-care guidelines, job aids, brochures,
and a training curriculum (in partnership with FHI and Alliance CI) and train care providers (physicians,
nurses, social workers, and community caregivers) in a complete palliative-care package.
• Document the impact of palliative-care services by tracking patient morbidity/mortality as well as
adherence to care and treatment. This information will inform the national policy as part of the program
Activity Narrative: evaluation, with technical assistance from JSI/Boston.
EGPAF's work complements the efforts of Alliance CI, CARE International, and FHI, which have community
capacity-building and empowerment activities in the same implementation areas. As agreed through an
MOU, Alliance-funded home-based care projects will link with EGPAF clinical sites to provide home-based
support to patients with advanced illness. EGPAF will also continue to work closely with the national HIV,
TB, and Reproductive Health programs, as well as other PEPFAR partners (CARE, PSI, ACONDA, and
ANADER), which have referral systems that usher patients into EGPAF's comprehensive care program.
At all sites, EGPAF 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. EGPAF
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
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.
Continuing Activity: 15111
15111 10336.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $700,000
10336 10336.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $250,000
Estimated amount of funding that is planned for Human Capacity Development $100,000
Estimated amount of funding that is planned for Water $20,000
Table 3.3.08:
This activity is supplemented by Track 1 funds (see separate entry).
By the end of Project HEART PY5, EGPAF will support 100 ART sites and will have more than 35,000
persons on ART. EGPAF will continue modest expansion in FY09 to an additional 15 sites and initiate
14,400 new persons on ART.
Through the district approach, ART services will be extended to rural areas in 14 targeted districts. In each
district, EGPAF will work with the district team to establish a network of facilities that will link one well
established ART site in an urban or peri-urban area with two or more rural ART sites. The urban sites will
then supervise and monitor the rural sites.
In FY08 EGPAF supported performance-based financing in 20 private and faith-based facilities.
CHU/Treichville will be the first public sector facility to implement performance based financing (direct
funding is possible due to CHU/Treichville's legal status). In FY09 EGPAF will add ten additional private
performance based sites in Abidjan. The expanded PBF approach should contribute to both the number of
patients enrolled in treatment and retained in treatment at these sites.
EGPAF will continue to expand public-private partnerships building on the successful experience with
SOGB to enable Ivoirian businesses to offer ART to employees. EGPAF would like to use the PBF
approach in the private, for-profit sector as this represents a major proportion of health services in urban
areas. However, EGPAF will need to advocate and work closely with the MOH and other relevant
departments as well as the PEPFAR team in-country to make this happen.
EGPAF intends to increase full laboratory support for patients receiving ART as well as patients in Pre-ART.
To attain these goals, with close collaboration with SCMS and with technical assistance of CDC lab branch,
new districts hospitals will be provisioned with equipment for measuring CD4 count, hematology,
biochemistry. Bases on SOPs validated in PY5, EGPAF will provide technical assistance to existing labs as
well as new labs to be established in FY09.
Focus in FY09 will be on the implementation of a comprehensive package of services to improve the overall
quality of services provided at all EGPAF-supported sites and address critical issues including attrition rates
within the program. Addressing these issues is part of a broader quality improvement program undertaken
in PY5 with the support of a subcontractor, John Snow International.
EGPAF will continue efforts to address QA/QI issues: districts QI teams will be developed and will lead in
improving quality of care in the districts under the supervision of EGPAF and Senior Health Management
Teams. Health facilities that perform well will be rewarded at the end of the PY with medical equipment and
infrastructure renovations. With PY6 funds, EGPAF will be working with many local CBOs to improve
services uptake. These CBOs will work closely with medical teams to address issues related to reinforcing a
family centered approach, adherence to treatment, and minimizing loss to follow up.
Special emphasis will be put on activities in the underserved North of the country. In order to improve the
coverage of activities in this area EGPAF will continue building on close collaboration with Health Alliance
International and UNICEF.
In both performance-based and cost-reimbursable formats, direct support to sites is provided in accordance
with national standards in terms of commodities, equipment, trained staff, laboratory services, and M&E.
Implementation is coordinated with PNPEC and may be direct (public sites) or through implementing sub-
partners. EGPAF seeks to ensure continuum-of-care services and service promotion at the community and
home levels (through partnerships with the network of PLWHA organizations, Alliance CI, CARE
International, ANADER, and other partners).
EGPAF works with SCMS and the Public Health Pharmacy (PSP) to support quantification and provide ARV
drugs and commodities at supported sites. Laboratory services are coordinated with the Ministry of Health,
APHL, CDC/Projet RETRO-CI, and the national network of laboratories.
FY09 funds will permit EGPAF to provide ongoing support to the planned 100 sites and 35,000 patients
expected to be on active ART by March 2009 as well as to provide services to 15 additional sites, for a total
of 36,700 people on active ART by September 2009.
While activities described above will provide the framework for care and treatment, several new initiatives
will be promoted to further strengthen the program. These include:
• Collaborate with local organizations to intensify HIV services promotion in the community and to
strengthen the capacities of community-based organizations;
• Further refine the performance-based contracting model and shift some partners currently supported
through cost-reimbursable grants to PBC;
• Expand the EGPAF quality assurance system to all supported sites;
• In collaboration with local NGOs and CBOs directly supported by EGPAF, EGPAF will work more closely
with social workers and community counselors (including PLWHA) to improve adherence to treatment,
reduce loss to follow-up, and provide psychosocial support, OVC care, and prevention for positives
interventions.
In a further attempt to institutionalize and make sustainable the activities supported by EGPAF with
PEPFAR funding, EGPAF's recent partnerships with and support of the National Medical and Social Worker
training institutions will be expanded to increase the human resources available to Côte d'Ivoire to fight the
Activity Narrative: HIV epidemic, prevent new infections, and treat people already infected with the virus.
In addition to the technical assistance received from CDC/Retro-CI for quality assurance for HIV testing,
EGPAF will seek technical assistance locally to address urgent issues related to QA for biochemistry and
hematology exams, including development of standard operating procedures and good clinical laboratory
practices.
EGPAF also plans to conduct an evaluation of strategies for retaining HIV-positive patients in care and
delaying progression to ART eligibility.
At all its PMTCT and ART sites, EGPAF 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.
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
HIV-negative clients at PMTCT, CT, and TB sites:
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.
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, EGPAF
will ensure that community-based services capable of meeting these needs are identified, and EGPAF will
be responsible for monitoring and reporting on referrals according to a nationally standardized referral
system.
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.
Activity Narrative: Based on the success of the program, in FY09 EGPAF will sign agreements with the pharmacy training
Continuing Activity: 15113
15113 4592.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $1,452,743
10068 4592.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $2,770,000
4592 4592.06 HHS/Centers for Elizabeth Glaser 3389 1477.06 EGPAF Rapid $2,150,000
Disease Control & Pediatric AIDS expansion
Table 3.3.09:
Since 2004 the Elizabeth Glaser Pediatric AIDS Foundation has received support from the US Centers for
Disease Control through Project HEART to provide a family-centered approach with a complete care and
treatment package for HIV-infected infants and children.
In FY08, the aim was to increase the total number of children enrolled in care. As of June 2008, EGPAF had
enrolled 3,945 children into HIV care. This represents 4.5% of the total number of HIV patients enrolled in
care in EGPAF programs and a major contribution to the total number enrolled in care in Cote d'Ivoire.
EGPAF's goal is at least 15%, so the program in Cote d'Ivoire has much work to do to reach this goal.
By March 2010, EGPAF plans to:
1) Initiate pediatric care at existing care and treatment sites that do not currently offer care for children
2) Improve quality of care through technical and material support via mentoring and on-site coaching in
collaboration with districts, training of medical staff and organization of regular meetings of personnel in
charge of HIV-positive children
3) Improve counseling skills of providers in helping mothers to make informed choices about infant feeding
by strengthening the capacity of nutrition services in health care facililties and social services for nutrition
support according to the guidelines of the national nutritional program and the experiences learned by
PATH and HKI in infant feeding and nutritional support in particular.
4) Initiate HIV screening at all points of entry for children: immunization visits, growth monitoring, nutritional
and social services, outpatient and inpatient consultations
5) To ensure early infant diagnosis (EID) and improve access to biological screening, EGPAF will facilitate
the logistics of transporting blood samples from sites to reference laboratories. To increase access to early
infant diagnosis, EGPAF will continue to work closely with CDC/ Retro-CI, whose lab capacity will be
expanded in FY09 to additional labs. EGPAF will work with the national care and treatment program,
laboratory and CDC to develop a sustainable plan for the transport of DBS samples via the postal service
with rapid return of results to sites via fax, internet, mail or transport. In FY09 EGPAF will increase access to
EID at 80 sites
6) In FY09 EGPAF will form a partnership with the Ivoirian Pediatric Board (SIP) to facilitate integration of
HIV Pediatric care activities into facilities by sensitization, trainings (both classroom and on-site mentoring)
and elaboration of national guidelines.
7) Provide appropriate psychosocial support to improve adherence to care and management of infected or
affected children and families. Psychosocial support will be provided to the medical staff in an effort to
prevent burnout.
New/Continuing Activity: New Activity
Continuing Activity:
* Child Survival Activities
Table 3.3.10:
In the program area of pediatric ARV treatment, almost 4% of the current patient load is pediatric cases,
and EGPAF is working assiduously to increase by 50% the number of children in care and treatment. The
pediatric treatment goals for FY09 include 1 816 new pediatric patients on ART, 3,534 pediatric patient who
ever received ART, and 2,385 pediatric patient receiving ART at the end of the reporting period.
- Key strategies for the coming year include:
• Implementation of a formal continuum-of-care "network model" to link women identified as HIV-positive in
PMTCT programs to ART programs and to enroll their HIV-exposed children in care and treatment
programs
Support a pediatric treatment communication campaign at the national level in collaboration with the MTN
Foundation (affiliated with the MTN cellular-telephone company) to increase awareness of pediatric
HIV/AIDS services;
• Using whenever possible (particularly at FBO AND CBO health facilities) a performance-based contracting
(PBC) model that reimburses partners based on a series of results rather than on a cost-reimbursable
basis.
• Expansion of the "district model" approach, working in close collaboration with health structures and
systems to share more responsibility with MOH staff in site selection, needs assessment, and supervision
• Expansion (to at least 80 sites) DNA PCR-based infant diagnostics to enroll more children at an early age
into care and treatment programs.
•support the national nutrition program to adapt/revise the guidelines and tools for infant feeding based on
WHO recommendations, in partnership with PNSI; PATH and HKI/Abidjan; and introduction of the WHO-
approved infant-feeding training curriculum for HIV-exposed children targeting doctors, nurses, and social
workers
• Expansion of program quality assurance to more than 25% of supported sites with the goal of reaching
more than 50% by the end of FY07
• Expansion of public-private partnerships to support more Ivorian businesses with their own health systems
or clinics in HIV prevention, care, and treatment.
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $4,000,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Background
Cote d'Ivoire faces a dual epidemic of TB and HIV, with an adult HIV prevalence rate of 3.9% (Report on the Global AIDS
Epidemic, UNAIDS 2008) and a TB incidence rate of 420 per 100,000 population (WHO, 2007), or approximately 84,000 cases.
Despite considerable efforts by the national TB program (PNLT), TB remains a serious public health threat in Cote d'Ivoire. The
TB case-detection rate remains low at 28% for all TB cases; in 2007, the TB case-notification rate was 108 per 100,000
population, with a total of 23,383 TB cases reported. Of these, 14,071 (60%) were smear positive (and thus 40% were smear
negative). The treatment success rate for patients registered in 2006 was 75%.
Despite setbacks due to the political-military crisis, with TB sites initially closed in the North and West, the TB program continues
to decentralize TB diagnostic and treatment services. The Ministry of Health (MOH) was awarded grants under Global Fund
rounds 3 and 6 to support these efforts. By August 2008, with support from the Global Fund, PEPFAR, and international NGOs,
96 health facilities throughout the country had the capacity to diagnose and treat TB cases using the DOTS strategy. With Global
Fund assistance, the PNLT plans to further decentralize TB diagnostic services to 15 more sites. Disruption of health services in
the northern and western parts of the country since 2002 has created concerns about increased multi-drug resistance to TB
medications.
HIV counseling and testing among TB patients shows that about 38% of TB patients tested are infected with HIV. TB remains the
leading cause of mortality among HIV-positive patients. Clinical trials in CI and elsewhere have shown that provision of
cotrimoxazole prophylaxis to TB/HIV co-infected patients reduces morbidity and mortality. National guidelines recommend that
ARVs be made available for eligible TB/HIV co-infected patients by providers trained to manage both infections. INH prophylaxis
is not yet supported by national policy in CI.
FY07 and FY08 Response
With PEPFAR support, the TB program is implementing routine provider-initiated opt-out HIV counseling and testing (PICT). The
program is also training health care workers in monitoring and management of TB/HIV co-infection. In coordination with the
National HIV Care and Treatment Program (PNPEC), PEPFAR-funded cotrimoxazole and ART are available in 68 TB diagnostic
and treatment centers (September 2008), with links to HIV treatment sites following completion of TB treatment. The USG is
supporting free "opt-out" testing programs at all 11 national TB specialist centers and 54 integrated TB diagnostic and treatment
centers (31 other TB care and treatment sites still need to implement routine opt-out PICT), resulting in 11,264 TB patients being
tested for HIV and identification of 4,370 TB patients co-infected with HIV in 2007. PEPFAR-supported sites are on track to
provide HIV tests and results to at least 20,800 TB patients with FY08 funds. PEPFAR partners are also expanding TB screening
at HIV-care clinics, and wraparound linkages have been created with the World Food Program to provide nutritional assistance to
TB/HIV co-infected patients.
In FY08, the USG is supporting improved smear microscopy through adaptation and roll-out of the CDC/WHO smear microscopy
training package and support for increased use of fluorescent LED microscopy (with support for maintenance of both old and new
microscopes) as part of the effort to increase TB case finding. The USG is also supporting the PNLT to improve the quality of
sputum smear microscopy by strengthening the quality-assurance system through external quality assessment by blinded
rechecking; this will be piloted with FY08 funds in Abidjan. Rapid TB liquid culture capacity will be established at two central
laboratories with MGIT technology - the Institut Pasteur-Cote d'Ivoire (the national TB reference laboratory) and CeDreS
(laboratory at the University Hospital in Treichville) - and one regional center (the CAT-Adjame, the largest TB treatment center in
Cote d'Ivoire) through a collaboration with FIND and UNITAID.
PEPFAR is supporting the PNLT to establish a system for transporting specimens from all TB clinics to one of the three central
facilities with culture capacity, followed by communication of results to the referring facilities. USG funds also will ensure
availability of basic laboratory equipment and supplies at central, regional, and peripheral laboratories. PEPFAR funds are
supporting procurement of specimen tubes and reagents for liquid MGIT culture, complementing procurements by FIND using
UNITAID funds over the next three years. Additionally, TB diagnostic capacity will be enhanced by the implementation of
molecular diagnostic techniques for TB diagnosis (when specimens are smear positive) and drug susceptibility testing (DST) with
support from FIND and UNITAID.
Implementing partners are working with the MOH to integrate HIV indicators within the national health system and at specialized
TB centers and integrated peripheral sites. Job aids and training tools for counselors and other professionals are being adapted.
PEPFAR partnerAlliance-CI is providing technical assistance and funding to CBO/FBOs linked to each major TB center to support
DOTS with community and home outreach. This has improved CT uptake and treatment adherence and completion, in addition to
helping families access HIV and TB diagnosis and care.
The PNLT has been effective in engaging increased district and regional health team involvement in the planning, coordination,
and monitoring of decentralized services. While the UNDP is the principal recipient on the Global Fund TB project, strong
programmatic leadership from the PNLT has assured programmatic success, with realization of all expected results through 2006
and approval of the second phase of the project.
FY09 Priorities
During FY09, the USG will build on previous achievements and continue to prioritize TB/HIV integration and expansion of service
coverage. PEPFAR will directly support the PNLT in training health care workers at TB and HIV care sites in comprehensive
TB/HIV co-management and program implementation. PEPFAR will support the PNLT in scaling up the new routine opt-out CT
strategy at all TB clinics, with a target of HIV testing for 80% of TB patients (approximately 19,200) by September 2009 and an
ultimate goal of 100% (about 24,000). USG partners will work with the PNLT to incorporate a TB screening tool into the national
HIV patient encounter form, which will be used by all USG partners for intensified TB case-finding among 100% of HIV-infected
patients attending HIV care and treatment sites at registration as well as at each follow-up visit. With the addition of 13 new sites
in FY09, the number of TB treatment sites supported by PEPFAR will increase from 96 to 109.
The USG will continue to support improvement of the quality of sputum smear microscopy at central, regional, and district level
health centers by strengthening the quality-assurance system through external quality assessment and on-site supervision. To
improve accuracy and speed of TB smear microscopy, fluorescent LED microscopy will be introduced and supported at 15-20
sites in FY09. The USG will also continue development and decentralization of rapid TB liquid culture capability using MGIT
technology to strengthen intensified TB case finding among HIV-infected persons, diagnosis of smear-negative TB, as well as
culture and drug susceptibility testing for TB cases failing primary treatment. The USG will also support the continued
development (with the financial and technical support of FIND and UNITAID) of molecular diagnostic capacity (at IPCI-Cocody,
CeDreS, and RetroCI, with the intention of eventual transfer of this capacity to the CAT-Adjame) for TB diagnosis and drug
susceptibility testing of smear positive specimens. Referral of specimens to the central laboratories will be facilitated by continued
development and strengthening of a TB laboratory network and specimen transport system that will support all TB diagnostic and
treatment centers.
In support of improved TB diagnostic imaging, the USG will support a pilot to implement the introduction of digital chest X-ray
imaging capacity (with improved image capability, computer-assisted interpretation, improved external quality control via computer
and expert remote radiographic interpretation of images transferred across the cell phone network, and elimination of the need for
continued procurement of X-ray film) at the largest TB treatment center (CAT-Adjame) and will pilot a mobile digital chest X-ray
system to service five to 10 additional TB/HIV treatment centers on a regularly scheduled basis.
As part of a family-centered approach, care for TB/HIV co-infected persons and their families will be linked with other prevention
and palliative-care services. A range of individually focused health education and support, referrals, community interventions, and
advocacy will be integrated. PEPFAR will continue to engage community-based organizations and NGOs to provide TB/HIV care
to co-infected patients in the community, with effective referrals to health-care facilities.
National TB recording and reporting tools revised by the PNTL to include HIV variables will be used by all PEPFAR-supported
sites for TB/HIV surveillance. The USG will also support the PNLT and PNPEC to implement an updated national TB infection-
control policy at all TB and HIV care and treatment sites in an effort to minimize nosocomial infections.
Implementing partners will provide technical assistance to incorporate relevant approaches into national policies and guidelines.
To improve the quality of care, partners will document experiences to inform program expansion and improvement. Of particular
interest are approaches to improve decentralized management and supervision, detect and link HIV- and/or TB-infected children
to care, improve TB detection at peripheral health facilities, and improve TB treatment adherence and completion rates.
USG efforts in TB/HIV aim to strengthen the national HIV and TB programs to carry out collaborative activities. USG inputs serve
to catalyze interactions between the two programs and among other key technical agencies. A workgroup including TB and HIV
program partners will be created to coordinate and monitor implementation of TB/HIV activities and will be reinforced with FY09
funding. While CI government commitment for TB/HIV collaborative activities is high, the political crisis has limited its ability to
maintain pre-conflict resource levels for the TB program. As stability returns, the CI government is expected to rebuild its capacity
to sustain TB/HIV activities.
Isoniazid Preventive Therapy: The USG team will work with the PNLT and PNPEC to develop a national policy related to IPT and
will support its implementation.
Coordination and Sustainability
Long-term technical assistance from USG/CDC, International Union Against Tuberculosis and Lung Disease (IUATLD), WHO,
FIND/UNITAID, PEPFAR partners (ASM, EGPAF, ICAP, ACONDA), and other experts is coordinated with the PNLT to promote a
synergistic approach. To assure cooperative support, PEPFAR partners are identifiable by their comparative advantages,
including service delivery and community support (EGPAF, ACONDA, ICAP-Columbia), laboratory services (Retro-CI),
commodities management (SCMS), human capacity (Abt Associates), and training and performance standards (TBD to follow
JHPIEGO).
Other major donors supporting TB/HIV activities in CI include the Global Fund and the Global Drug Facility, providing a three-year
stock of adult TB drugs; WHO, assuring in-service training and supervision and providing limited financial support; IUATLD,
evaluating the TB program; FIND/UNITAID, supporting improved TB diagnostics, primarily at the central level; and Belgian Project
FORESA, facilitating TB diagnostics in rural health facilities.
All USG-funded partners will report to the PEPFAR strategic information team with quarterly program results and ad hoc
requested program data. To help build a unified national M&E system, all USG-funded partners will participate in quarterly SI
meetings and will implement decisions agreed upon during these meetings.
Table 3.3.12:
For EGPAF, TB/HIV is an important area of intervention. Based on a close working relationship with the
national TB program (PNLT), EGPAF has been able to offer TB screening in most ART sites supported
(currently at 62 health facilities). Support offered to facilities to provide TB services includes training of HIV
care providers in management of TB, organization of services that enables TB patients to benefit from HIV
and TB care in the same location, equipment and minor renovations and improved quality of services
through supervision and program monitoring.
As noted in FY08 CAT Adjame (which cares for approximately ¼ of all TB patients in the country) was able
to reconfigure its patient flows and services, with the support of EGPAF, and now offers 90% of all TB
patients an HIV test. CAT Adjame continues to serve as an example and in FY09 EGPAF plans to organize
study visits from other TB centers to see this model in action.
In FY08 the estimated HIV co-infection rate for TB patients was 50%, however, based on experience the
actual rate is closer to 37-39%. Therefore the number of new TB patients with HIV is estimated to be 6,000
in FY09, rather than the 8,000 estimated in FY08.
Support offered to sites includes:
- Training of health workers
- Equipment for 20 laboratories, such as Bunsen burners, 12 kg gas bottles, ventilation hoods, shelves,
furniture and fans
- Minor renovations where necessary to improve patient flow at the 10 TB sites, more major renovations are
planned for CAT Koumassi and CAT Yamoussoukro
- Community counselors are an important link between patients and TB centers and assist with improved
adherence and regular patient follow-up. High volume TB sites will have community counselors assigned to
them.
- Supervision with PNLT and PNPEC of HIV/TB activities
- Extension of quality assurance to include TB
In PY6 the following TB screening among HIV patients will be intensified:
- In FY08 PNLT and EGPAF developed screening algorithms to improve TB diagnosis among HIV-positive
patients. In FY09 these screening algorithms and tools need to be widely disseminated to all EGPAF-
supported ART sites
- Inclusion in HIV patient medical records a list of essential screening questions for active case finding of TB
to be asked of all HIV patients each time they are seen at a health facility
- EGPAF will work closely with PNLT to achieve its goal of offering TB diagnosis within certain HIV care and
treatment centers. EGPAF proposes to offer TB screening services in the ten largest HIV care and
treatment sites. This would entail the ability of sites to collect TB sputum cultures and transport them to
CATs with TB diagnosis capacity. A successful pilot phase will allow for a rapid expansion among EGPAF-
supported sites.
- Intensified TB screening will require the development of an improved laboratory network. EGPAF will
support PNLT in their policy to decentralize TB diagnosis by liquid culture and molecular techniques.. PNLT
will also acquire ten new binocular microscopes.
Another important component of the PY6 TB activities is infection control. TB transmission in health facilities
is a known risk. The risk is serious for both health care workers and patients. Unfortunately the measures to
prevent nosocomial infection in Cote d'Ivoire are generally insufficient. As HIV causes increased
susceptibility to TB, the following measures need to be put into place to address this issue:
- Training of health care workers to understand the risks of nosocomial infection and take preventive
measures, such as triage for patients giving priority to those who are coughing or the posting of signs and
other IEC materials to encourage patients to cover their mouths when coughing
- Improve the ventilation in waiting rooms and consultation rooms in TB and HIV centers usually made
possible with minor renovations
- Protective gear for health care workers such as masks (N95), use of air extractors in laboratories and
other potentially contagious areas as well as the encouragement of testing for TB and HIV among health
care workers.
Integration of TB and HIV services is an overarching goal for Project HEART and the whole
PEPFARprogram. Integration is being achieved through the provision of routine HIV counseling and testing
(CT) services at TB diagnostic sites, provision of TB and HIV care for co-infected patients at TB treatment
sites, and TB screening and referral at all HIV service sites.
To date, EGPAF has assisted the Ministry of Health (MOH) to provide free routine HIV testing (moving from
an "opt-in" to provider-initiated routine CT) in six specialized TB centers with a case load of more than
10,000 patients a year out of the annual country-wide case load of 21,000 active TB patients. These
activities have resulted in greatly improved HIV testing uptake among TB patients and the identification of
HIV-infected TB clients in need of joint HIV and TB care.
Activities include increasing clinical capacity to provide routine provider-initiated CT services, implementing
a functional referral system (linking clinics providing HIV and/or TB diagnosis with those providing HIV and
TB care and treatment services), enhancing community-level support to promote adherence and successful
treatment outcomes, and care for families of HIV- and TB-affected persons through screening for TB and
HIV in the household. PEPFAR funds will be used to train health-care providers, perform minor facilities
renovation if needed, and provide ARVs through a coordinated procurement process at the national level.
EGPAF in collaboration with the national TB control program (PNLT) and leading TB care providers have
Activity Narrative: been taking the leadership to change national policy and designed new training curriculum and materials to
support a rapid scale-up of this new strategy across the country.
In support of the national priorities of the TB and HIV programs and in collaboration with PEPFAR and other
partners, EGPAF will use FY09 funds to:
• Strengthen activities undertaken during PY 05 at the current 44 EGPAF-supported TB sites (8 CATs and
36 CDTs) and 57 ART sites
• Expand support for TB/HIV activities to 21 additional CDTs
• Continue to provide a comprehensive package of services to the existing 101 (44 Tb clinics + 57 HIV sites)
TB/HIV sites and the 8,400 new TB/HIV patients to be enrolled into HAART by the end of March 2009
• Collaborate with PNLT to roll out the provider initiated counseling and testing approach at all the TB
clinics. EGPAF will ensure that at least 80% (about 10,490) of all TB patients diagnosed at the supported
sites are tested for HIV. All the co-infected patients will be given cotrimoxazole prophylaxis.
• Revise the patient flow patterns used at all the CAT and CDTs supported by EGPAF based on those
implemented at CAT Adjame and Cocody to systematically offer HIV testing earlier and provide the results
on the same day.
• Systematically screen all patients attending HIV care and treatment sites at registration and each follow up
visit using the TB screening tool developed by PNLT.
- INH prophylaxis will be given to eligible patients according to national guidelines.
• Implement the newly adopted simplified HIV testing algorithm using finger prick test and/or oral testing to
increase the uptake of HIV testing at the main eight regional TB centers and CDTs supported by EGPAF
• Continue working in close collaboration with the TB control program recipient of the Global Fund TB grant,
and the lung disease specialists health professional association to improve TB/HIV diagnosis (including
children) as part of a family-centered approach, with follow-up of family members of the HIV/TB co-infected
clients
• Expand TB screening, diagnosis, and treatment of HIV-infected patients at "HIV" points of entry (CT,
PMTCT, etc).
• Improve and expand quality assessment and improvement activities in the eight regional TB centers to
improve the overall quality of services provided to TB/HIV co-infected patients and their families
• Conduct training for all categories of staff working at TB/HIV care centers (medical doctors, nurses, social
workers and community care givers) using the new training curriculum and tools
• Provide additional trained staff at the TB centers in the Central, and Northern regions of the country where
there are severe human resource shortages while working with the Ministry of Health, donors and UN
agencies involved in the fight against HIV/AIDS to hasten the redeployment of government health workers
in these regions
• Support to organize information and coordination meetings at the district and regional levels as well as
facilitate exchange visits between TB and HIV treatment centers
• Provide resources to regional TB centers and districts to strengthen their data management capacity and
also enable them to perform regular formative supervision activities
• In collaboration with PNTL and ASM, support decentralization of rapid TB liquid culture to regional TB
clinics in the central, northern and western regions of the country.
• Infection control measures including administrative controls and renovations as required will be done at all
the CATs.
• Support TB culture for all cases of treatment failure as well as for diagnosis of smear negative cases;
support integration of molecular diagnostic techniques (line probe assays and DST) into TB diagnostic
services, working in collaboration with PNLT, ASM, FIND, and IPCI.
In addition an emphasis will be put on:
• Wraparound activities involving TB and HIV NGOs, CBOs, and FBOs dealing with TB and HIV to deepen
and update their understanding and knowledge of TB-HIV co-infection related issues, in partnership with
other PEPFAR partners and in particular with Alliance Cote d'Ivoire linked to EGPAF by a MOU signed in
June 2007. With the support of PAM, EGPAF will also extend its food aid program to malnourished TB/HIV
co-infected patients including children.
• Joint planning and coordination to increase system-strengthening efforts in M&E (JSI); laboratory
(APHL/RETRO-CI); commodities management (SCMS); and human capacity, training, and performance
standards (Abt Associates/JHPIEGO/CCP). Ongoing technical assistance will be sought from the USG,
WHO, and other experts. Availability of TB commodities will be assured by the national TB program with
support from the Global Drug Facility.
• Building sustainability through the empowerment of both government institutions (HIV, TB programs) and
community organizations dealing with TB/HIV co-infection: joint planning, trainings, sensitization campaigns,
and reinforcement of M&E capacity. EGPAF will provide medical, IT, and logistic equipment as needed.
Activity Narrative: not representative of the majority of public sector settings in which providers in Cote d'Ivoire will work. In
Continuing Activity: 15112
15112 5041.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $1,895,000
10057 5041.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $1,950,000
5041 5041.06 HHS/Centers for Elizabeth Glaser 3389 1477.06 EGPAF Rapid $1,000,000
In FY09 EGPAF will more aggressively identify OVCs through counselors or providers who will
communicate with HIV-positive adults are enrolled in care at supported facilities. During individual and
group counseling sessions the providers will encourage parents to have their children tested. To better
identify OVCs through individuals enrolled in HIV prevention, care and treatment services, EGPAF will
utilize the OVC identification form created by the national OVC program (PNPOEV).
In addition to on-site activities, community counselors primarily identified from local organizations, will
conduct home visits to assess the living conditions of OVCs and determine whether there are overwhelming
needs for additional resources or services and determine how these needs can be met. Needs could
include nutritional support or income generating activities.
EGPAF works with nine local organizations that are responsible for approximately 1,800 orphans and
vulnerable children. The Activity plans will be developed in collaboration with the local organizations to
determine how EGPAF support is most beneficial. Some possible activities for FY09 include: education
tutors to help children to stay in school, organization and formalization of children's support groups and
exchanges with other groups, children's camps for adolescents living with HIV for more in-depth
psychosocial support for the other children struggling with social issues and questions about sexuality and
reproduction and a holiday party for children.
The package of care for OVCs includes:
- Reinforce the capacity of nine local organizations both in technical and managerial aspects
- Make tools available to sites to assist in the identification of OVC
- Psychosocial support to OVCs provided by counselors during home visits and in peer support groups.
Support groups allow for an open discussion of issues facing youth.
- Tutoring in school subjects for in-school youth in need of additional educational support
- Sensitization and testing of all children of HIV-positive family and caregivers
- Linking families with income generating opportunities
- Nutritional support especially for infants 6-24 months and malnourished children under the age of five
- Medical care for all children seen at EGPAF-supported sites
Additionally, EGPAF will supply educational materials and OVC materials in waiting rooms high volume
pediatric centers (CHU Treichville, CHU Cocody, Centre PIM Abengourou, Centre SAS and CIRBA) for all
children and caregivers to read.
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
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.
Activity Narrative: clean water and bed nets for palliative care and educational, medical, nutritional, legal, and psychosocial
Continuing Activity: 17119
17119 17119.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $340,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $5,000
Estimated amount of funding that is planned for Education $50,000
Table 3.3.13:
During FY08, 20 organizations funded via performance-based financing have dramatically improved their
counseling and testing capacities (approximately 20 persons per organization per day tested during the past
six months). As this model has grown, greater emphasis will be put on payment for HIV counseling and
testing services.
Tertiary health institutions and private sector organizations under PBF will be encouraged to work more
aggressively to counsel and test their outpatients and inpatients. Advancing on this front is of the highest
priority for the funds being requested for FY09.
The new algorithm for whole blood finger-prick testing was validated by the MOH in FY08 and is poised for
country wide roll out in FY09. As the new testing algorithm does not require refrigeration or a centrifuge as
was formerly the case, it will be possible to implement it at all sites at all levels of the health care pyramid.
This new algorithm should allow a much more aggressive approach to HIV testing, enabling routine opt-out
or provider initiated testing to take place, as well as mobile testing possibilities.
All EGPAF existing sites (100 at the end of PY5) as well as the new ones to be established (69 during PY6)
will be implementing routine opt-out or PICT and EGPAF will support implementation of the new testing
algorithm in all ART sites to improve uptake of results. Within the district approach to be extended to 14
districts, a closely coordinated system of a referral and counter referral—between primary care sites
providing testing but not treatment and officially designated art sites—will be implemented.
Inpatients at all tertiary (CHUs) and secondary level hospitals (regional and districts hospitals) and
outpatients at all levels of the health care system will be targeted for intensified routine opt-out C&T.
EGPAF will participate in supporting a National HIV testing day to be organized by the National Network of
PLWA and the Ministry for the Fight Againt HIV/AIDS by encouraging all HIV care and treatment sites to
receive local populations seeking HIV testing. Persons testing HIV positive will be referred for care and
treatment as appropriate. With the support of CBOs, couples and family testing will be encouraged.
To help achieve these ambitious goals, EGPAF will advocate with the National HIV care and treatment
program (PNPEC) to facilitate the creation and implementation of innovative training models (including HIV
in the workplace training) to reach more than 600 caregivers.
EGPAFs aims to counsel and test at least 155,000 patients during FY09.
In the first three months of 2007, 16,716 people (excluding PMTCT clients) were counseled and tested in
sites supported by EGPAF. At the CHU/Treichville alone, 2,846 people were tested in the five services that
have adopted this approach, and 981 of these have been put on ART. These patients supplement the
steady growth of ART patients in the Infectious Disease Unit (SMIT), the main center for ART at CHU-
Treichville. As this initiative is only just starting, it is imagined that the number of patients tested at the CHU-
Treichville will continue to increase this year, and the program should test approximately 40% of the
estimated 30,000 hospitalized patients in Treichville by the end of 2008. In addition, this public site will
receive a performance-based financing grant to improve overall HIV activities, including counseling and
testing.
The CHU-Cocody has also begun to expand HIV counseling and testing, initially offered in the pulmonary,
neurology, internal medicine departments and other clinics in FY08.
Both institutions will be encouraged to work more aggressively to counsel and test their outpatients. They
have about 125,000 outpatient consultations a year combined; assuming a typical patient has two visits per
year, this represents a pool of 62,500 potential CT clients per year. Since ambulatory cases present with
fewer disease symptoms than hospitalized cases, it has been more difficult to convince overworked staff to
counsel and test outpatients. Advancing on this front is of the highest priority for the funds being requested
for FY08.
Results might have been even more impressive if not for frequent stock-outs in test kits over the past year.
Even when the Public Health Pharmacy (PSP) was able to deliver test kits, it has frequently delivered fewer
than requested, causing all EGPAF sites to offer testing to fewer patients than they would have otherwise.
In addition, these stock-outs have a tendency to de-motivate the hospital staff to pursue HIV testing.
EGPAF has partnered with the local NGO GROFORMED to extend the model developed at CHU-Treichville
and CHU-Cocody to four regional hospital complexes in the interior of the country. The expected adoption
of a simplified finger-prick, whole-blood testing algorithm for HIV infection should enable EGPAF to expand
into rural zones that do not have linkages to laboratories. Combined with necessary policy changes and
training and supervision, the simplified algorithm will enable nurses and midwives to provide CT services, a
requirement for the program to be successful outside larger cities.
Another NGO, Renaissance Sante Bouake, with EGPAF technical and financial support has started a
demonstration home-based CT intervention in four villages around Yamoussoukro, with planned expansion
to four more villages at the end of March 2009. EGPAF in close collaboration with the national VCT working
group and technical assistance and support from the CDC/VCT team and infectious disease association
(GROFORMED) is in the process of documenting this and other CT approaches it has implemented in Côte
d'Ivoire over the past few years, including:
• The EGPAF continuum-of-care strategy implemented at PMTCT sites in Abengourou, Agnibilekro, and
Grand Bereby
• Family-based models piloted in Bouaké
Activity Narrative: • Extension of CT through family-planning sites
• Routine CT at TB centers, with greatly increased uptake
EGPAF is working closely with the CT working group at the National HIV/AIDS Care and Treatment
Program (PNPEC) to document practices that will enable PNPEC and its partners to go to scale with proven
strategies.
With FY09 funding, EGPAF's priorities will include the following CT intervention strategies:
• Reinforcement of CT for hospitalized patients and a push to greatly increase testing of ambulatory patients
in the large Abidjan hospitals supported by EGPAF
• Integration of CT in 80% of the regional hospitals and of districts in the intervention zones of EGPAF's
Project HEART
• Continued expansion of routine CT for all TB patients in TB treatment centers and progressive
decentralization of this activity out toward health facilities with TB "corners"
• Greatly expanded numbers of infants tested using PCR (initially through the transport of whole blood, then
moving toward a DBS strategy for sites farther from PCR laboratories). Children testing HIV-positive will be
offered access to treatment as part of the family approach and linked to on- or off-site OVC services.
• Expanded home-based CT strategies around five well-performing HIV care sites
• Improved linkages of care and treatment activities, including TB/HIV, PMTCT, and STI clinics, with access
to ART eligibility screening for all HIV-positive patients and to comprehensive palliative care for those not
eligible for ART, with referral to OVC services for their children
• Improved M&E systems that will enable EGPAF to identify clients who have not been picked up through
ongoing care and treatment and PMTCT programs (i.e. a system that allows tracking of which clients are
being picked up by specific CT approaches).
"Prevention for positives" interventions will be conducted in partnership with RIP+ (national network of
PLWHA organizations) and technical assistance from PEPFAR's special Prevention with Positives initiative
at CHU-Treichville and at least three faith-based or community health centers. An aggressive community
awareness campaign promoting CT will be undertaken using media, community leaders, peer educators,
and local drama groups, in close collaboration with JHU-CCP, REPMASCI (network of journalists and
artists), and Alliance-CI.
Partner and couples testing will be a high priority, building on a stronger family-centered approach in
Bouake, Yamoussoukro, Ouangolo, Ferke, Dimbokro, and Sainte Thérèse Enfant Jesus in Abidjan.
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, EGPAF will ensure that community-based
services capable of meeting these needs are identified, and EGPAF will be responsible for monitoring and
reporting on referrals according to a nationally standardized referral system.
Activity Narrative: EGPAF will expand both of these programs to include 50 additional medical and 100 social work students.
Continuing Activity: 17081
17081 5045.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $550,000
10062 5045.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $550,000
5045 5045.06 HHS/Centers for Elizabeth Glaser 3389 1477.06 EGPAF Rapid $700,000
Table 3.3.14:
In FY08 EGPAF developed indicators and tools to accompany the performance based financing (PBF)
activities, currently these are paper-based, but an electronic tracking system will greatly increase the
efficiency of reporting on this program. All 30 PBF sites will have access to this electronic system.
With PEPFAR-supported HIV/AIDS services scaling up and Cote d'Ivoire moving toward peace and
stability, EGPAF is now able to provide full support to project sites throughout the country. Strong
monitoring and evaluation of the whole program is essential to improve the quality of services, ensure that
lessons learned are disseminated, work toward sustainable models of service delivery that can eventually
be taken over by the MOH, and report the most accurate numbers possible.
In FY08, EGPAF has supported 26 health districts to be computerized for data management, and fifteen
individual ART sites have implemented a temporary database for the longitudinal follow-up of patients and
program management while waiting for the finalization of a national tool. Ten health districts and five sites
have received telephone and Internet for data transmission; twelve districts have received motorcycles and
EGPAF provided fuel to seven districts to collect data from far-flung sites and continue technical assistance
in M&E to sites. EGPAF has also supported significant training in the area of SI, including training of 33
health districts in epidemiologic data collection and conducting two training sessions (involving 36 data
managers and M&E foal points at district and site level) with health districts on the importance of feedback
throughout all levels of the health system and on working through mechanisms by which regional and
district health authorities can communicate such information back to the site level. To this end, EGPAF
organized three data review meetings at district level. Keys obstacles were identified and corrective actions
were undertaken. Members of the EGPAF SI team participated in the four quarterly SI meetings organized
by the USG strategic information branch and implemented decisions agreed upon during these meetings.
In order to improve data management at district and site levels, EGPAF copied all national HIV data
collection tools and sent them to more than 170 sites receiving its support.
As part of a collaborative process to develop a national electronic patient tracking system (EPTS) called
SIGVIH, EGPAF participated in the pilot phase of SIGVIH deployed at five EGPAF-supported sites. EGPAF
contributed four consultants for three months in FY08 and signed an agreement with DIPE to make 26 data
entry clerks available to implement the new system at sites where SIGVIH was installed.
EGPAF's SI team has also provided continue technical assistance in data management to 33 health
districts.
The need for EGPAF's performance-based sub-partners to track patient visits closely, coupled with the
generally poor quality of patient records in the country, has led EGPAF in FY07 to develop a series of
patient record forms, each linked to a particular type of visit, and an accompanying database that will allow
both grant recipients and EGPAF to follow program progress closely, with the added benefit of allowing for
computer-based quality-assurance approaches. (EGPAF's current QA approach depends on the random
selection of a sample of patient records on site). This patient record monitoring approach piloted at five sites
in FY07 has been rolled out to thirty sites supported by performance-based contracts in FY08. Despite
encouraging results, many challenges remain:
1) The absence of indicators that permit longitudinal follow-up of mothers and children identified as HIV-
positive in PMTCT
2) A lack of standard registers or standard patient records
3) A lack of a consistent referral system allowing tracking of referrals and counter-referrals
4) Difficulty in determining ART patient status (deaths, drop-outs, and transfers) due to the lack of a unique
patient identifier
5) A lack of systematic approaches to data collection on laboratory activities
6) A lack of computerization at most of the sites
7) A very small number of personnel devoted to M&E at the district and site levels
FY09 funds in the program area of SI will be used to conduct the following activities:
EGAPAF 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 managers and 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 quarterly, 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 agreed upon during these meetings.
Site- and District-Level Activities
EGPAF will:
1) Hire, orient, and continually train and supervise 15 additional site-level data clerks as necessary.
2) Provide data-processing equipment and supplies (computers and accessories) to sites and health
districts; provide and train staff in the appropriate software for each type of service; equip pharmacies and
laboratories with computers and adequate software for HIV commodities management; provide needed
Activity Narrative: logistical support for data collection and transmission; provide M&E tools (registers and other materials) at
site and district levels; and provide transportation and IT equipment needed for M&E activities (Internet,
photocopiers, phone cards, motorbikes, bikes, fuel, etc.). At least ten data manager's offices will undergo
minor renovations to facilitate better management of patient records and data. Addionally, EGPAF will
maintain the wireless network installed in the university hospital complex (CHU) of Treichville.
3) Continue training in M&E and quality assurance.
Strengthening of National SI Activities
In support of the national SI system, EGPAF 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 EGPAF'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. EGPAF will expand data-quality improvement activities with technical assistance from JSI and in close
collaboration with the PEPFARSI team and district data managers.
3. Collaborate with the PNPEC and other partners to develop and implement a unique patient identifier to
track patients.
5. Contribute commodities data to 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
PEPFARprograms in Cote d'Ivoire.
6. In close collaboration with DIPE, MEASURE and CDC, EGPAF will provide funds to organize a national
two week M&E course similar to the CESAG course. Around 30 data managers will be trained,
7. The foundation will provide two to three scholarships (as an award) to the best district data managers to
attend the CESAG M&E courses in Dakar
8.The foundation will support a fellowship program with the aim of training one to two newly graduate
students in the M&E field.
9. Organize regular working sessions with the MOH and other key stakeholders for the deployment of
tools for data management at all EGPAF-supported sites.
10. EGPAF will work closely with other SI partners - including the MLS and MOH data-management
divisions for the deployment of the national data-collection software as well as ISPED-Bordeaux, ACONDA,
and ICAP-CU - while providing specific technical and logistic support at district and site levels, including
ensuring availability of all validated M&E tools.
To promote sustainability, the hiring of staff will be conducted in close collaboration with the MOH and other
government decentralized entities (mayors, general councils).
Continuing Activity: 15114
15114 5053.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $600,000
10074 5053.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $600,000
5053 5053.06 HHS/Centers for Elizabeth Glaser 3389 1477.06 EGPAF Rapid $600,000
Estimated amount of funding that is planned for Human Capacity Development $50,000
Table 3.3.17:
EGPAF contributes to the national response to the HIV/AIDS epidemic in Cote d'Ivoire by mitigating the
impact of the HIV/AIDS epidemic. The EGPAF approach to health systems strengthening is to reinforce the
health care system to overcome barriers to improved health and promote sustainability.
The reinforcement of the health sector constitutes a major area of intervention by EGPAF in FY09, with
prioritization of four primary areas of intervention:
1) Support for pre-service training of medical and non-medical personnel
2) Holistic support for decentralized health care services through a district approach
3) Development of partnerships with MOH at the central level and with civil society
4) Strengthen institutional support to local organizations
Pre-Service Training
In order to address the perpetual problem of lack of health care personnel, which constitutes one of the
major barriers to the expansion of HIV care services, EGPAF signed agreements in 2007 and 2008 with the
following institutions:
- University of Cocody School of Medicine- This partnership trains medical students in the final year of their
course work while they are preparing a thesis. The program is focused on HIV, TB and malaria, the three
major endemic diseases with the greatest morbidity and mortality in Cote d'Ivoire. In the first year there
were 19 students who benefited from theoretical training and a six month practicum in rural health care
facilities supported by EGPAF with PEPFAR funding. Based on the success of the program, there was a
request from the university for expansion. In FY09 this program will include 50 medical students.
- National Institute of Social Work (INFS)- This partnership includes the training of 50 social work students
in their gap year between coursework and the assignment of a government position. During their six month
site placements, trainees are active in the development of pre and post test counseling, ART adherence
education and psychosocial support for OVCs. This program has also been successful and EGPAF was
requested expand support to 100 students in FY09.
Based on lessons learned from the pre-service training experience with doctors and social workers, EGPAF
envisions additional similar collaborations in FY09 with additional academic institutions:
- University of Cote d'Ivoire Pharmacy and Biological Sciences partnership will provide placements for 25
students in their final year of pharmacy training in the domains of drug and lab reagent supply chain
management and logistics.
- Institute of Nurse Midwife (INFAS) partnership will provide placements in PMTCT programs for 25
midwives at the end of their training.
Reinforce operational support and expand the district approach: EGPAF plans to share experiences gained
using this approach which was demonstrated as effective in Abengourou District to contribute to the rapid
scale-up of ART, PMTCT and VCT by effectively doubling the coverage of services. The EGPAF approach
is above all to facilitate the participation of communities and health actors within the health care system to
increase their capacity through training and increasing access to high quality public health services.
In FY09, 14 districts will benefit from this approach. Specific interventions will include:
- Improve the coordination of HIV/AIDS services by the district health team and infrastructure necessary
including: conference space with training material for district trainings, computer equipment at the district
level, and minor renovations to health facilities and pharmacies
- Support for refresher training for health care workers in HIV care
- Provision of laboratory equipment
- Facilitate the availability of consumables and lab reagents
- Donation of vehicles (3 per district) for the supervision of high performance districts
- Support for the transport of lab samples, supervision visits and coaching of health care workers
- Reinforce the management capacity of the district health team through national and international training
courses
Health Care Financing
Based on EGPAF's successful experience introducing performance based financing (PBF) in private and
faith based facilities, in FY09 the next step will be to pilot performance based financing in two health
districts. This strategic approach links payments to performance is an alternative method for funding
HIV/AIDS activities. The results will be shared with other health sector partners with the expectation that this
method could be scaled up nationally.
It's important to note that the implementation of these activities is dependent upon ongoing negotiations with
the health authorities at the highest level to identify the appropriate funding mechanisms.
Partnerships with MOH and Civil Society: EGPAF expects to provide awards for different governmental
entities to provide support to:
- National M&E Unit (DIPE) for the recruitment and support of 25 data managers per year for three years.
While their role will concentrate on data entry and analysis related to HIV care and treatment, these data
managers will also support data management for other health programs as well.
- National maintenance Unit (DIEM) to revitalize this entity so that it is able to fufill its mandate which
includes maintenance of laboratory equipment in public health facilities. EGPAF will work with the MOH to
study the possibilities for a formal collaboration to reinforce local maintenance units (CRIEM) in Abengourou
and San Pedro.
- National Reproductive Health Program (PNSR/PF)-to introduce PMTCT activities in targeted antenatal
Activity Narrative: consultation sites
- Additional partnerships with professional organizations and civil society are envisioned, such as with
GROGORMED (an association of infectious disease doctors) and the Ivoirian pediatricians association to
develop a mentoring and preceptorship program to be implemented on-site.
Program to reinforce local organizations
Given the organizational, managerial, programmatic, financial and accounting challenges, EGPAF has
contracted two external management consulting firms to assist in the reinforcement of these organizations.
The support has benefited ten local organizations in FY08. Ten additional organizations will be enrolled for
FY09.
The activities being implemented and planned will improve EGPAF's efforts to reinforce health services
through both the public and private sectors. These activities will be implemented in close collaboration with
the Ministries (MSHP and MLS) and other partners of the US Government. These activities will
progressively reinforce the decentralization of health care services in a country weakened by six years of
conflict.
Continuing Activity: 15115
15115 10337.08 HHS/Centers for Elizabeth Glaser 7045 5306.08 EGPAF Rapid $150,000
10337 10337.07 HHS/Centers for Elizabeth Glaser 5306 5306.07 EGPAF Rapid $150,000
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.18:
