The Family AIDS Initiative: Scaling-up Family-Based Approaches to Care and Treatment in Cote d’Ivoire Joseph Essombo, Anthony Tanoh, Toure-Penda Diagola Diomande Ouohi, Lathe You Jeanine

Country Context Population = 18.1 million Adult HIV prevalence = 4.7% (2005 AIS) with gender and geographic disparities Approximately 750,000 PLWHA; currently only 17% of those who are eligible are receiving HAART An estimated 45,000-55,000 HIV-infected women delivering per year in need of PMTCT services and follow-up; only 4.3% are receiving antiretroviral (ARV) prophylaxis EGPAF works in CI since April 2004 to expand comprehensive HIV care, treatment, and PMTCT services through essentially a family-centered model As of March 08, EGPAF-CI has been supporting 77 ART sites and 129 PMTCT sites in 12 regions out of 19 (63%) and 30 health districts out of 72 (42%) through CDC-funded Project HEART

All patients CURRENTLY on care and treatment (March 08) Care and Support 1 Antiretroviral Treatment 2 AdultsChildrenTotalAdultsChildrenTotal Project HEART Care and Treatment Achievements as of March 08 Care and Support 1 Antiretroviral Treatment 2 Total % Children % Females Total % Children % Females %65% %64% Proportion children and females CURRENTLY on care and treatment (March 08)

Project HEART PMTCT Achievements as of March 08 Number of ANC visits Number of pregnant women tested Number of HIV positive women Number of HIV positive women receiving ARV prophylaxis Number of infants receiving ARV prophylaxis

Severe impact of the HIV epidemic on the household –High number of HIV-orphaned children ( ) –Increased poverty PMTCT challenges: –Low coverage and poor uptake of PMTCT services –Less than 10% of children enrolled into care Introduction of early infant diagnosis using DBS PCR and a new simplified HIV testing algorithm Rationale for family-based approach (1)

Provide care to the family as a single entity –Target all siblings of each index HIV positive case –Provision of care to the family in the same HIV clinic Country policy issued in 2006: –Free HIV testing for all –Free cotrimoxazole prophylaxis for all –Free ART for children and half price for couple ($2/month) Rationale for family-based approach (2)

HIV Positive Index Case Partners Tested for HIV in Care and Treatment Settings (Sites=11)

HIV Positive Pregnant Women’s Partners Tested for HIV (Sites= 57)

Center SAS Family Approach Couple counseling and couples discussion groups Child-friendly services to complement clinical care Wrap-around services like food support and income generating activities for families New patients requested to identify a family member to support them in adherence Home visit to support disclosure or assess social situation DBS/PCR available for infants under 18 months Support groups: mixed (men, women and children), women's only and youth only As of December 2007: 3240 families were enrolled 5534 children with 26 % both parents orphaned 235 HIV-infected children in care

Renaissance Santé Bouaké: Family Home-Based VCT Approach Started in June 08 in five villages with an average of 2000 inhabitants each Package of preventive services including: –Family HIV counselling and testing with same day results –Adults: screening for other chronic disease: TB, high blood pressure, diabetes, anemia and leprosy –Children: clinical screening of malnutrition, Vitamin A supplementation, deworming, anemia and immunization status –Referral for care to the village health center or RSB clinic for HIV positive adults and children –Results as of end of June 08: 356 adults (40% couples) and 144 children 10 HIV positive adults and 1 HIV positive child

Still challenging to reach partners and sibling of the index case due to: High level of stigma Care providers used to taking care of individual rather than a family Data collection tools not adapted to track information related to family care Challenges

A good strategy to increase acceptance of PMTCT services in the community and offer adequate care to serodiscordant couples Definitely move from PMTCT to PPTCT for greater involvement of males Community involvement is the cornerstone to implement a vibrant family approach Urgent need to streamline sufficient funding to support stigma reduction interventions Lessons Learned

Acknowledgements Staff and clients of Center SAS in Bouake and Renaissance Sante in Yamoussoukro This presentation was made possible through support provided by the U.S. Centers for Disease Control and Prevention (CDC), through the President’s Emergency Plan for AIDS Relief (PEPFAR), as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Project HEART”/Cooperative Agreement No. U62/CCU123451). The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of CDC.