Cote d’Ivoire Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

COTE D’IVOIRE

Project Title: Cote d’Ivoire Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Total Funding
	Allocated as of February 2008			Allocated June 2008			Allocated as of June 2008
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	New Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	300,000	300,000	-	-	-	300,000	-	300,000
DOL	-		-	-	-	-	-	-	-
HHS	5,253,000	48,322,269	53,575,269	-	(2,428,000)	(2,428,000)	51,147,269	13,634,903	64,782,172
Peace Corps	-		-	-	-	-	-	-	-
State	-	250,000	250,000	-	1,525,000	1,525,000	1,775,000	-	1,775,000
USAID	-	51,527,731	51,527,731	-	1,303,000	1,303,000	52,830,731	850,000	53,680,731
TOTAL	5,253,000	100,400,000	105,653,000	-	400,000	400,000	106,053,000	14,484,903	120,537,903

HIV/AIDS Epidemic in Cote d'Ivoire:
Adults (aged 15-49) HIV Prevalence Rate: 4.7% (AIDS Indicator Survey, 2005)
Estimated Number of People Living with HIV: 750,000
Estimated number of Orphans due to AIDS: 324,000

Country Results and Projections to Achieve 2-7-10 Goals:

Cote d'Ivoire	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	27,100	4,500
End of FY 2005**	33,800	11,100
End of FY 2006***	65,200	27,600
End of FY 2007****	115,200	46,000
End of FY 2008*****	213,000	57,500
End of FY 2009*****	385,100	80,000

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Cote d'Ivoire is beginning to emerge from a deep politico-military crisis that for three years divided the territory and impoverished the population. Despite significant hardship and instability, the country remains a regional economic and migratory hub. A significant portion of the population of 19 million consists of immigrants from the sub-region, and approximately half of the population lives in rural areas. Cote d’Ivoire has the highest national HIV prevalence in West Africa; both HIV-1 and HIV-2 viruses are prevalent. With an overall adult HIV prevalence of 4.7%, Cote d'Ivoire has a generalized epidemic marked by striking gender and geographic differences, early sexual debut, intergenerational and multiple concurrent sexual partnerships, weak knowledge about HIV transmission and prevention, and low condom use. In all age groups, females are far more likely than males to have HIV and prevalence rates peak among women ages 30-34 at 14.9%, vs. 5.6% of men of the same age. Male prevalence may be mitigated by near-universal (96%) circumcision. Geographically, prevalence ranges from 1.7% in the Northwest to near 6% in the South and East and 6.1% in Abidjan. Populations at high risk for acquiring and transmitting HIV include sero-discordant couples, the uniformed services and ex-combatants, people in prostitution, economically vulnerable women and girls, truckers and mobile populations, sexually active youth, and orphans and vulnerable children. Tuberculosis (TB) is the leading cause of AIDS-related deaths; results of HIV counseling and testing among TB patients show that 36% of TB patients tested are co-infected with HIV.

The USG is by far the largest supporter of HIV/AIDS efforts; in 2007, USG support represented 70% of the budget dedicated to HIV/AIDS in Côte d’Ivoire. Coordinated by the host government, the interagency PEPFAR team, and implementing partners, the fight against HIV/AIDS in Cote d’Ivoire is steadily moving forward and achieving important gains. Significant results in treatment and care, including care for vulnerable children, are being secured through an emphasis on building local capacity and ensuring sustainability.

The following programmatic areas will be funded in FY 2008 to stem the growth and mitigate the impact of the epidemic in Cote d’Ivoire:

Prevention: $24,169,292 ($16,856,646 Field; $7,312,646 Central) (23.7% of prevention, care and treatment budget)

Primary HIV prevention priorities include a comprehensive abstinence, be faithful, and correct and consistent use of condoms (ABC) prevention approach emphasizing delay of sexual debut, partner reduction, condom use for high-risk groups, stigma reduction, and gender equity. PEPFAR will continue to expand public- and private-sector BCC interventions at the community level and in targeted high-risk populations. Focus will be placed on reinforcing the roles of parents and caregivers in influencing social norms that promote abstinence and fidelity and address risk factors such as alcohol and drug use. Behavior change activities will emphasize delay of sexual debut and acquisition of life skills with positive gender roles for in- and out-of-school children and youth; a decrease in cross-generational and coerced sexual relationships; the promotion of fidelity coupled with HIV testing within sexual partnerships; risk reduction among high-risk populations; and decreased hospital-related infection through expanded blood-safety and injection-safety programs.

Among high-risk populations, interventions will target the uniformed services and ex-combatants, truckers, displaced and mobile populations, people in prostitution and their clients, sexually active youth, and health- and education-sector workers. Activities will be expanded to promote HIV testing and management of sexually transmitted infections (STIs) among underserved populations. For people in prostitution and truckers, the USG will continue to support services, including static clinics with peer outreach, that provide support, CT, condom-negotiation skills, and STI management, as well as links to health and HIV care, treatment, and social and legal services. These complement and are coordinated with USAID and World Bank regional projects targeting transport routes.

With USG support, the national prevention of mother-to-child transmission (PMTCT) program will expand to additional sites. In addition to HIV testing and ARV prophylaxis, the comprehensive package of interventions promoted at PMTCT sites includes assessment for and provision of ART; low-risk obstetrical practices during delivery; postnatal services; infant-feeding support; cotrimoxazole prophylaxis; infant follow-up and basic pediatric care; infant HIV diagnosis; linkages to community-based care and support, including OVC services; prevention for positives and discordant couples; and program monitoring and quality assurance. The USG will continue the rapid integration of routine HIV testing in health-care facilities, including the integration of PMTCT services in antenatal care through a strengthened family-centered approach.

Principal Partners: Agence Nationale d’Appui au Developpement Rural (ANADER), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Hope Worldwide Cote d’Ivoire (HWCI), Population Services International (PSI), John Snow International (JSI), Johns Hopkins University, JHPIEGO, Family Health International (FHI), CARE International, National Blood Transfusion Service/Ministry of Health, Social and Scientific Systems Inc., Alliance Nationale Contre le SIDA (ANS-CI), ACONDA-VS, Ministry of Education, Projet RETRO-CI, EngenderHealth, ICAP/Columbia University, RIP+ (NPI), Le Soutien (NPI), Geneva Global (NPI).

Care: $24,018,989 ($23,568,989 Field; $450,000 Central) (23.6% of prevention, care and treatment budget)

As scale-up of HIV/AIDS services continues, PEPFAR will improve the quality and expand the geographic coverage of HIV counseling and testing (CT), care, and support for persons living with HIV/AIDS (PLWHA) or affected by HIV/AIDS, including OVC. The country program will ensure that all USG-supported services meet quality standards, contribute to national priorities, and can be taken to scale with available resources. In FY 2008, the USG will prioritize full implementation of routine CT in health facilities, including provider-initiated CT to all TB clinics in the country. USG partners will work with the Ministry of Health (MOH) to finalize the TB screening tool and algorithm for diagnosis of TB among HIV-infected persons.

FY 2008 strategies for improving care will focus on evidence-based, life-saving preventive interventions; training and supervision for care providers; and strengthening of support and links through trained, full-time counselors at all health facilities. Cotrimoxazole will be provided free to all adults with CD4 counts of less than 500 and to children according to WHO guidelines, with targeted provision of insecticide-treated bed nets and clean-water products. Counselors at all antiretroviral treatment (ART) and PMTCT sites will provide HIV-positive clients with a comprehensive package of HIV prevention interventions for all clients and effective support, follow-up, and referrals to community- and home-based palliative and OVC care services. USG partners will continue to implement comprehensive clinic- and community-based care programs that include clinical monitoring, pain management, nutritional support and counseling, promotion of good hygiene, assessment and management of HIV-related psychosocial problems, end-of-life bereavement care, and succession planning and referrals for OVC.

About 16% of children are OVC (AIS, 2005), including 8% who have lost at least one parent to AIDS. The USG has supported participatory development and dissemination of a national strategic plan and a national OVC policy and M&E plan defining the national priority to support OVC within families and communities. In FY 2008, USG will build on progress in strengthening the capacity of local organizations to identify, assess, and meet the needs of OVC while strengthening systems to coordinate, manage, and track progress at the local, district, and national levels. While supporting direct services for 63,000 OVC, PEPFAR will support the National OVC Program (PNOEV) in mapping OVC needs and services, ensuring strategic placement of providers, and defining and implementing a strategy for rapidly scaling up high-quality, sustainable services. Referral systems will be strengthened through facility-based counselors, and a network model for linking OVC to other health, education, and social services will be replicated. PEPFAR partners will work with national stakeholders (including the Ministry for Technical and Vocational Training and the private sector) to develop strategies for meeting the needs of especially vulnerable children and youth, including older OVC, girls, and young children

Principal Partners: Population Services International (PSI), Johns Hopkins University, National OVC Program (PNOEV)/Ministry of Family and Social Affairs, Hope Worldwide Cote d’Ivoire (HWCI), CARE International, Family Health International (FHI), Ministry of Education, National TB Program/Ministry of Health (MOH), Agence Nationale d’Appui au Developpement Rural (ANADER), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), JHPIEGO, Projet RETRO-CI, Alliance Nationale Contre le SIDA (ANS-CI), ACONDA-VS, Partnership for Supply Chain Management (SCMS), ICAP/Columbia University, Academy for Educational Development (FANTA), PATH, Population Council, Save the Children UK, American International Health Alliance Twinning Center, CDC Lab Coalition, RIP+ (NPI), Le Soutien (NPI), Geneva Global (NPI).

Treatment: $53,488,469 ($46,766,212 Field; $6,722,257 Central) (52.7% of prevention, care and treatment budget)

With USG support, Cote d’Ivoire continues to succeed in scaling up comprehensive HIV/AIDS treatment services nationwide. The National HIV/AIDS Care and Treatment Program expects to meet the PEPFAR five-year target of 77,000 persons under ART by the end of FY 2008, despite significant delays in the second phase of the Global Fund HIV grant that have left the USG as the primary funding source for treatment services and commodities procurement since 2006. At the end of June 2007, 26,878 patients were on ART with direct support from PEPFAR partners, and the Global Fund was supporting an additional 8,580 ART patients. PEPFAR will provide ongoing technical assistance and small grants to enable PLWHA and media organizations and networks to promote treatment literacy and uptake of HIV counseling and testing, provide peer support, and work to reduce gender- and HIV-related stigma and discrimination.

To achieve these ambitious goals, PEPFAR efforts focus on developing systems that provide a continuum of comprehensive care and treatment services through an innovative family-centered approach, with a treatment package that includes laboratory services, early infant diagnosis, antiretroviral (ARV) drug therapy, adherence support and monitoring, psychosocial support, palliative care, treatment of opportunistic and sexually transmitted infections, ARV-resistance testing, care for HIV-affected families with prevention of further infections, targeted program evaluations, and data management. Additional treatment partners in FY 2007 and the reactivation of Global Fund treatment efforts will allow geographic extension of ART services, especially in the underserved North and West, with careful attention to coordination and quality assurance. The USG will continue to strengthen key systems that are critical for scale-up of quality sustainable treatment services monitoring (including for the emergence of ARV resistance) through a health management information system and targeted evaluations; pre-service and in-service training for health professionals; capacity building for decentralized health authorities; and the establishment of a laboratory network supported by the CDC/Projet RETRO-CI laboratory, which provides a majority of national HIV testing and monitoring.

PEPFAR has consolidated most of its procurements and is working closely with the Public Health Pharmacy (PSP) and USG partners on the specifications of all commodities. First-line ARV drugs are procured by USG and stored regionally, with three-month buffer stocks to avoid stock-outs at PEPFAR-supported service-delivery sites. A key priority for FY 2008 will be ensuring that accurate monthly inventory and dispensing data from every treatment site is received and analyzed at the PSP and is used to inform service-delivery planning decisions by all stakeholders. Supply data will be routinely compared with facility-specific patient records to monitor adherence to MOH prescriptive protocols and to confirm that all commodities are accounted for and distributed where most needed. Supply-chain managers and technical advisers will work closely with the strategic information sector to link these two complementary tracking systems. The USG partners will participate in quarterly updates of national forecasts and joint procurement planning with other commodities suppliers, particularly the new GF principal recipient.

Principal Partners: Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), ACONDA-VS, ICAP/Columbia, Johns Hopkins University, Population Services International (PSI), CDC Lab Coalition, Partnership for Supply Chain Management Systems (SCMS), Family Health International (FHI), Agence Nationale d’Appui au Developpement Rural (ANADER), Projet RETRO-CI, Alliance Nationale Contre le SIDA (ANS-CI), University Research Co. (URC).

Other Costs: $18,861,153

PEPFAR continues to work to fill critical information gaps and support coordination and planning with the Ministries of the Fight Against AIDS (MLS), Health (MOH), Education, and Family and Social Affairs (for OVC) as well as donors and other key stakeholders. The USG will continue to support the MOH in developing and strengthening its facility-based health information system as part of a strategic information plan for HIV/AIDS activities in the health sector. Partners will work collaboratively to improve the quality of information collected at each level by providing training and equipment, harmonizing indicators, developing data-collection tools for community-level use, and developing training manuals. The USG will continue to support technical assistance to disseminate WHO data-collection tools. Additional USG support will assist Cote d’Ivoire in building capacity in skilled human resources, informatics, and communications infrastructure and systems. Support will also be directed toward building a unified M&E system to capture HIV-related information from CT, PMTCT, and ART sites, to reinforce linkages among sites, and to facilitate effective use of data at different levels of the health system.

Cross-cutting activities will focus on building human and organizational capacity; creating and strengthening public-private partnerships and leveraging additional resources; strengthening planning, coordination, and advocacy efforts; and reducing HIV- and gender-related stigma and discrimination. The USG will continue to support the strengthening of the Ivorian government’s capacity to train and retain adequate human resources for the delivery of quality HIV/AIDS services. Efforts will include matching of pre-service training with real-world needs; support for the reopening of nursing schools in central and northern regions; and exploration of innovative ways to encourage and deliver continuing education using information technology, print materials, and other accessible media. In collaboration with the national network of PLWHA, the Ministry of Labor, and the Ministry of Professional Teaching, USG implementing partners will explore the possibility of creating a new cadre for PLWHA working as lay counselors, to help sustain their involvement in the HIV/AIDS response. The USG will also provide technical support to the MLS to strengthen the coordination of workplace interventions, the documentation and dissemination of best practices, the standardization of quality assurance and M&E tools, and the implementation of regular participatory program reviews and supervision. In addition, PEPFAR will work to strengthen its engagement with Cote d’Ivoire’s private sector.

Principal Partners: TASC 3/John Snow International, Ministry of the Fight Against AIDS (MLS), Family Health International (FHI), Partnership for Supply Chain Management Systems (SCMS), Ministry of Health (MOH), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Projet RETRO-CI, ACONDA-VS, JHPIEGO, ICAP/Columbia University Abt Associates, AIDSTAR, Johns Hopkins University, EngenderHealth, Management Sciences for Health.

Administrative funds will support program-management costs to implement and manage PEPFAR. HHS and USAID personnel, travel, management, and logistics support in country will be included in these costs.

Other Donors, Global Fund Activities, and Coordination Mechanism:

While PEPFAR is by far the largest donor, other development partners active in the HIV/AIDS sector include the Global Fund for HIV, TB and Malaria (originally with UNDP as principal beneficiary serving the North and West of the country, now with CARE International, July 2007-December 2008), the UN and other international organizations (WHO, UNICEF, UNDP, UNFPA, UNAIDS, WFP, MSF, etc.), and to a limited extent other bilateral partners (the Belgian, Canadian, French, German, and Japanese cooperations). A large potential source of funding is the World Bank MAP which continues to be delayed. The PEPFAR Country Coordinator represents the USG on the Global Fund Country Coordinating Mechanism (CCM) and at most coordination forums, while agency heads (CDC and USAID) represent the USG at technical forums. The Ministry of AIDS’ National Strategic HIV/AIDS Plan (2006-2010) provides new forums for coordination that will improve overall communication and programming for HIV/AIDS activities. The UNAIDS theme group has expanded to include the USG to provide a regular coordination forum bringing multilateral and bilateral development partners together. Substantial efforts are being made to promote coordination and collaboration among in-country partners, the host government, and other key stakeholders. As the country’s political context stabilizes, the USG team will continue to explore leveraging and wraparound opportunities with other donors and the private sector.

Program Contact: PEPFAR Country Coordinator, Jyoti Schlesinger

Time Frame: FY 2008 – FY 2009

Approved Funding by Program Area: Cote d'Ivoire