Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) Project Cooperative Agreement No. AID-OAA-A-14-00045

DEMOCRATIC REPUBLIC OF THE CONGO QUARTERLY PROGRESS REPORT JULY 1 TO SEPTEMBER 30, 2018

OCTOBER 31, 2018

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 0 LINKAGES DRC Quarterly Progress Report July 1 to September 30, 2018

Overall Achievement This quarter marks the end of strong year of implementation for Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) Democratic Republic of the Congo (DRC). The project exceeded all annual targets for female sex workers (FSWs) and reached most targets for men who have sex with men (MSM). This quarter (Q4), case finding rates, linkage to care, and viral load (VL) testing coverage all increased notably compared with Q3. The project continued to benefit from central TOM+ funds, which were allocated to targeted technical assistance (TA) from LINKAGES headquarters (HQ), as well as to training and seed funding to improve implementation. An index testing strategy was developed and incorporated into activities, and HIV self-testing started. Enhanced peer outreach approach (EPOA) activities and risk assessment tools were reinforced to improve reach and testing services. Additionally, LINKAGES DRC signed a subagreement with a key population (KP)/MSM-led organization (Jeunialissime), launched a community service delivery point (CSDP) with a trained nurse in Kasumbalesa, and conducted programmatic mapping in two health zones (Rwashi and Kampemba) that will be covered in FY19.

1. Summary of Key Results • 3,390 FSWs, 1,338 MSM, and 735 FSW clients were reached with HIV prevention interventions. • 3,165 FSWs, 1,077 MSM, and 707 FSW clients were tested and received their results. • 321 FSWs (10.1 percent), 102 MSM (9.5 percent), and 53 FSW clients (7.5 percent) tested positive for HIV. • 283 FSWs (88.2 percent), 87 MSM (85.3 percent), and 43 FSW clients (81.1 percent) were newly enrolled in care and initiated on antiretroviral therapy (ART). • 107 Zambian KPs (103 FSWs and 4 clients of FSWs) were reached with HIV prevention interventions in cross-border activities; 90 FSWs and 4 clients of FSWs were tested and received their results; 17 FSWs (26.4 percent) tested positive for HIV, and 13 of them were initiated on ART. • 110 people living with HIV were enrolled at one of LINKAGES’ drop-in center (DIC) points of distribution: 53 FSWs, 54 MSM, and 3 FSW clients, including 44 in Haut-Katanga (18 newly enrolled) and 66 in Kinshasa (11 newly enrolled). • 299,452 male condoms, 34,822 female condoms, and 21,206 lubricant packs were distributed. • During EPOA campaigns conducted in Kinshasa, Lualaba, and Haut-Katanga, 591 FSWs and 103 MSM were tested for HIV, and 63 FSWs and 13 MSM tested positive. For FSWs, this yielded a 10 percent case finding rate (similar to Q3), but for MSM, the case finding rate increased from 9.5 percent (Q3) to 12.5 percent (Q4). 56 FSWs and 11 MSM were newly enrolled in care and initiated on ART. • 384 KPs/priority populations were screened for sexually transmitted infections (STIs) in DICs, including 313 FSWs, 35 MSM, and 36 FSW clients. • 17,261,000 Congolese Franc (CDF) (~USD $10,788) were saved by 19 KP saving groups. • The organizational performance index (OPI) was implemented for 4 LINKAGES implementing partners (IPs) with 31 key participants (PSSP, Bak Congo, Faradja, Lamuka). • 1 CSDP was launched at Kasumablessa in Haut-Katanga. • Programmatic mapping was conducted in 2 new health zones in Haut-Katanga (Rwashi and Kampemba).

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 1

TOM+ funding contribution to DRC project success

This quarter, LINKAGES DRC received funding for TA, training, and implementation from USAID DC TOM+ funds. This funding was critical to finish the fiscal year successfully. TOM+ funds allowed the project to achieve the following performance as of Q4: ✓ FSWs: 130 percent of KP_PREV target reached, 107 percent of HTC_TST target reached, and 86 percent of linkage-to- care target reached. ✓ MSM: 147 percent of KP_PREV target reached, 47.6 percent of HTC_TST target reached, and 83 percent of linkage-to- care target reached.

In addition, TOM+ funds have been instrumental in the implementation of multiple trainings for IP staff, peer educators (PEs), peer navigators (PNs), and outreach workers (ORWs) to improve the scope and efficacy of services offered. Topics covered in these trainings included correct use of the risk assessment tool, use of ICT, quality improvement of HIV testing services (HTS) sessions, implementation of index testing and HIV self-testing (HIVST), capacity building of HIV case managers and providers to administer motivational interviewing, and strengthening of the EPOA strategy. All of these trainings positively affected program performance, especially case findings, in the last quarter of FY18.

TOM+ funds were also used for EPOA TA to improve the ways we track, monitor, and guide risk and HIV-positive KP networks to reach more individuals within those networks. This work will be continued in FY19 Q1: EPOA site plans will be developed for all provinces, and our capacity to capture data will be improved through weekly network analysis reviews to better target productive networks.

2. Result Areas

Result Area 1: Increase availability of comprehensive prevention, care, and treatment services, including reliable coverage across the continuum of care for MSM and FSWs

• Provided comprehensive services in DICs: The four DICs continued to provide safe spaces for KPs with additional options for accessing services. Services included social and behavior change communication (SBCC), HIV testing and counseling (HTC), STI screening and treatment, referral for HIV case management, condom and lubricant distribution, and psychosocial support, including recreational activities. Three DICs are being used as points of distribution of ART to stable HIV- positive KPs (see additional details on points of distribution further below). During this quarter: ➢ 2,567 KP individuals were registered in the four DICs (1435 FSWs, 999 MSM, and 133 FSW clients), of which 782 benefited from HTS and 384 were screened for STIs (313 FSWs, 35 MSM, and 36 FSW clients). ➢ DIC committee meetings continue to be held regularly, which improves institutional capacity. ➢ The Lubumbashi DIC was visitedE by the U.S. Centers for Disease Control and Prevention (CDC) and Programme National de la Lutte contre le SIDA (PNLS) to discuss the upcoming integrated biological and behavioral survey. ➢ A new MSM-led community-based organization (CBO), Jeunialissime, joined LINKAGES DRC as a partner at the end of Q4. The partner has a safe space in its office where prevention activities are conducted, including HTC, psychosocial support, and distribution of condoms and lubricants.

• Launched a CSDP in Kasumbalesa: Following a USAID recommendation, made during a visit in July of FY18, to improve the availability of community services for KPs in Kasumbalessa, a CSDP was LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 2 developed. Through the CSDP, HTC, STI screening and treatment, family planning services, ART initiation, psychosocial support, and condom and lubricant distribution are available through a trained nurse. Data on services provided and number of beneficiaries served will be reported in the following quarter (FY19 Q1).

• Strengthened EPOA: Using TOM+ funds, an EPOA campaign was organized in the three LINKAGES provinces. Through this EPOA campaign, we reached 745 KPs, including 591 FSWs and 154 MSM, and we tested 694 KPs, including 591 FSWs and 103 MSM. Among those tested, 73 KPs tested positive for HIV (63 FSWs and 13 MSM), which represents a case finding rate of 10.7 percent for FSWs and 8.4 percent for MSM. The results are similar to overall case finding rates for Q4 (10.1 percent for FSWs and 9.5 percent for MSM). In addition, EPOA contributed to better linkage to care for both FSWs and MSM.

• Started HIVST: In line with the LINKAGES DRC FY18 work plan, HIVST implementation began this quarter using oral fluid test kits (World Health Organization pre-qualified OraQuick HIV self-tests). This testing method allowed the project to reach those who are not reached by existing HTS, especially high-risk KPs who may not otherwise participate in outreach HTS sessions or visit DICs because of perceived stigma or confidentiality concerns. During Q4, 315 self-test kits were distributed to KPs, and 247 were used (111 by FSWs, 124 by MSM, and 12 by FSW clients). Sixty-one kits were reactive, and 49 were confirmed positive. All positive KPs were linked to ART. The case finding rate was 18.8 percent for both KPs and FSW clients. HIVST has positively and significantly affected HIV case finding during the reporting quarter when compared with overall case finding obtained with regular testing methods for the same quarter.

• Strengthened voluntary partner referral strategy: To improve case finding, emphasis was put on expanding implementation of the violence prevention response (VPR) strategy to enable KPs living with HIV (KPLHIV) to make life-saving referrals to HTS for members of their social and risk networks. After implementing a training of community providers, including PNs, the following results were achieved: 28 index cases (16 FSWs, 11 MSM, and 1 FSW client) were contacted, and 56 contacts were referred to HTS (11 FSW, 26 MSM, 6 FSW clients, 11 biological children, and 2 female FSW clients). Thirty-six of those referred tested positive, including 4 FSWs, 5 FSW clients, 5 biological children, 1 FSW client’s spouse, and 21 partners of MSM. All HIV-positive cases were linked to ART services.

• Reinforced community-based ART distribution: As in past quarters, the three points of distribution continued to provide ART services to the stable KPLHIV referred by Integrated Health HIV/AIDS Project (IHAP) health facilities. During Q4, all points of distribution began initiating ART services to newly diagnosed HIV-positive KPs during HTS outreach sessions and at DICs. This intervention reduces the number of individuals lost to follow-up. From July to September 2018, the points of distribution achieved the following results: - 110 KPLHIV were enrolled into care at the points of distribution: 53 FSWs, 54 MSM, and 3 FSW clients, including 44 in Haut-Katanga (18 newly enrolled) and 66 in Kinshasa (11 newly enrolled). - 384 KPs were screened for STIs in DICs, including 313 FSWs, 35 MSM, and 36 FSW clients, and all received STI treatment from the nurses leading the points of distribution.

• Managed commodities (condoms, lubricants, HTS commodities, and STI drugs): During Q4, the project distributed 299,452 male condoms, 34,822 female condoms, and 21,206 lubricant packs.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 3 Condom distribution is done by PEs and PNs based on the need (volume of clients) and risk level of each KP member. Chemonics Project provided LINKAGES with 7,300 Determine, 440 Unigold, and 200 Vikia tests to be used in HTS sessions. Additionally, during this reporting period, LINKAGES made a large range of STI drugs available to KPs at all LINKAGES-supported sites.

• Followed up VL testing for eligible HIV-positive KPs: This quarter, LINKAGES focused on increasing PNs’ awareness of the importance of VL testing and on ensuring availability of VL data for eligible KPs enrolled at all LINKAGES sites. A list of all KPLHIV eligible for VL testing was developed to identify programmatic gaps and produce a remediation plan to track individuals eligible for VL testing. As of the end of September 2018, 1,880 FSWs and 376 MSM living with HIV were enrolled in care and received ART. Of those, 687 FSWs (35 percent) and 159 MSM (42 percent) were eligible for VL testing, and 499 FSWs and 147 MSM received testing. In total, 175 FSWs and 43 MSM received their VL testing results, and 164 FSWs (93.7 percent) and 41 MSM (95.3 percent) had an undetectable VL. These results were made possible by TOM+ funds, which supported TA and related activities, including transport fees for community workers to track eligible KPs and those who missed their VL testing appointments. Figures 1, 2, and 3 provide further data points and progress throughout the life of the project.

Figure 1. Treatment part of cascade: VL testing & suppression among HIV-positive FSWs, Life of Project

2500 2269

2000 1704 75.1% 1500 40.3%

54.9% 1000

Numer of Numer of FSWs 687 45.1% 377 500 70.6% 170 120

0 FSWs tested FSWs initiated on FSWs eligible for FSWs tested for FSWs received VL FSWs with VL positive for HIV ART VL testing VL results suppressed

Care and Treatment Indicators

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 4 Figure 2. VL samples collected among FSWs in DRC, Life of Project

200 187 180 160 140 120 120 109 100 80 60 40 34 20 14 20 3 3 2 7 0 FY16 Q3 FY16 Q4 FY17 Q1 FY17 Q2 FY17 Q3 FY17 Q4 FY18 Q1 FY18 Q2 FY18 Q3 FY18 Q4

Total Viral Load Sample collected

Figure 3. VL Samples Collected among MSM in DRC, Life of Project

80 76 70

60

50

40

30 27 20 15 16 10 6 1 4 2 0 FY17 Q1 FY17 Q2 FY17 Q3 FY17 Q4 FY18 Q1 FY18 Q2 FY18 Q3 FY18 Q4 Total viral load sample collected

• Provided comprehensive prevention, care, and treatment services to KPs in three provinces. The map in Figure 4 shows the areas of intervention: Kinshasa, Haut-Katanga, and Lualaba.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 5 Figure 4. LINKAGES DRC geographical coverage

The following services were provided in each province this quarter: • 5,463 KPs, including 3,390 FSWs, 1,338 MSM, and 735 FSW clients, were reached in Q4 with at least one of the follow services: HIV prevention key messages, referral for HTS, and distribution of condoms: - 777 FSWs, 1,028 MSM, and 214 FSW clients reached in Kinshasa. - 1,187 FSWs, 310 MSM, and 83 FSW clients reached in Haut-Katanga. - 1,426 FSWs and 438 FSW clients reached in Lualaba. • 4,949 KPs, including 3,165 FSWs, 1,077 MSM, and 707 FSW clients, benefited from HTS and received their results in the three provinces: - 662 FSWs, 855 MSM, and 195 FSW clients tested in Kinshasa. - 1,115 FSWs, 222 MSM, and 80 FSW clients tested in Haut-Katanga. - 1,388 FSWs and 432 FSW clients tested in Lualaba. • 476 KPs, including 321 FSWs, 102 MSM, and 53 FSW clients, tested positive for HIV. The overall case finding rates were 10.1 percent for FSWs, 9.5 percent for MSM, and 7.5 percent for FSW clients: - 11 percent of FSWs (74), 9 percent of MSM (79), and 5 percent of FSW clients (10) tested positive in Kinshasa. - 11 percent of FSWs (120), 10 percent of MSM (23), and 20 percent of FSW clients (16) tested positive in Haut-Katanga. - 9 percent of FSWs (127) and 6 percent of FSW clients (27) tested positive in Lualaba. • 413 KPs were newly enrolled in care and initiated on ART: 88 percent of FSWs (283), 85 percent of MSM (87), and 81 percent of FSW clients (43): - 91 percent of FSWs (67), 85 percent MSM (67), and 70 percent of FSW clients (7) in Kinshasa. - 85 percent of FSWs (102), 87 percent of MSM (20), and 75 percent of FSW clients (12) in Haut-Katanga. - 90 percent of FSWs (114) and 89 percent of FSW clients (24) in Lualaba. LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 6 FSW Cascades and Analyses: Figures 5 to 14

Summary: LINKAGES DRC performed well with FSWs this quarter: 3,390 FSWs were reached, and 3,165 (93.4 percent) received HTS and their results. Of those tested, 321 (10.1 percent) were found to be HIV- positive, of whom 283 (88.2 percent) were enrolled in care and initiated on ART. This overall success is the result of reinforced supervision and coaching of PEs and ORWs who supervise PEs, along with community mobilization activities. The EPOA campaign also supported case finding, and close collaboration between PNs and health institution providers improved linkage to care.

Figure 5. Cumulative prevention and treatment cascade for FSWs in DRC, FY18 FSW: Prevention part of the FSW: Treatment part of the cascade, FY18 cascade, FY18 1,000 16,000 14,276 900 321 3,390 10.1% 88.2% 14,000 93% 3,165 800 283 100% 283 12,500 12,000 700 3,673 3,452 600 569 296 10,000 512 512 260 260 8,000 500 4,768 400

6,000 4,445 Number FSWs Number of Number FSWs Number of 300 250 4,000 212 212 4,432 4,188 200 2,000 100 203 169 169 - FSWs reached FSWs tested for - HIV FSWs tested HIV- FSWs newly enrolled FSWs newly enrolled postive in care in treatment Prevention Indicators Care and Treatment Indicators FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 7 Figure 6. HIV prevention cascade for FSWs in Kinshasa, Haut-Katanga, and Lualaba provinces, FY18 Kinshasa, FSW: Prevention part of Haut-Katanga, FSW: Prevention Lualaba, FSW: Prevention part of the cascade, FY18 part of the cascade, FY18 the cascade, FY18 7,000 7,000 6,500 6,500 7,000 6,000 6,000 6,500 1,426 97.3% 5,808 5,500 5,500 6,000 1,388 5,500 5,000 5,000 5,050 1,187 93.9% 4,427 4,500 5,000 4,041 4,500 1,115 3,850 4,500 1,579 1,537 4,000 3,600 85.2% 4,000 777 1,212 4,000 3,500 3,500 662 1,119 3,500 3,000 882 3,000 796 3,000

NumberFSWs of 2,500 1,976

Number of FSWs NumberFSWs of 2,500 1,934 2,500

1,533 NumberFSWs of 2,000 1,352 2,000 2,000 1,259 1,159 1,500 1,500 1,500 1,000 1,000 1,000 1,532 1,370 1,773 1,734 500 1,127 1,084 500 500 - - - FSWs Reached FSWs tested for HIV FSWs Reached FSWs tested for HIV FSWs Reached FSWs tested for HIV Prevention Indicators Prevention Indicators Prevention Indicators FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target

Reach: More than 108 percent of the quarterly reach target was met, and the annual target was exceeded by 130 percent. Several factors can be credited with this success, including the EPOA campaigns, enhanced monitoring and coaching by IP teams, and higher motivation of PEs as a result of quarterly performance-based incentives. The annual targets were surpassed in all three provinces (Kinshasa, Haut-Katanga and Lualaba) with some variations in success.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 8 Figure 7. Care and treatment cascade for FSWs in Kinshasa, Haut-Katanga, and Lualaba provinces, FY18 Kinshasa, FSW: Treatment part of Haut-Katanga, FSW: Treatment Lualaba, FSW: Treatment part of the cascade, FY18 part of the cascade, FY18 the cascade, FY18

400 400 400

350 350 350 120 127 89.8% 85.0% 300 300 300 114 100% 114 102 100% 102 250 74 90.5% 250 250 236 212 212 67 100% 67 104 85 200 200 200 175 76 76 158 158 94 158 94

107 142 142

Number FSWs of Number FSWs of 150 Number FSWs of 150 150 90 90 77 110 99 99 100 100 58 58 100 63 55 55 50 50 89 50 69 69 70 44 40 40 60 60 - - - FSWs tested FSWs newly FSWs newly FSW tested HIV- FSWs newly FSWs newly FSWs tested FSWs newly FSWs newly HIV-postive enrolled in care enrolled in postive enrolled in care enrolled in HIV-postive enrolled in care enrolled in treatment treatment treatment Care and Treatment Indicators Care and Treatment Indicators Care and Treatment Indicators FY18 Q1 Results FY18 Q2 Results FY18 Q1 Results FY18 Q2 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q4 Results FY18 Q3 Results FY18 Q4 Results FY18 Q3 Results FY18 Q4 Results FY18 Target FY18 Target FY18 Target

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 9 Figure 8. HIV case finding rate by age among FSWs, FY18 – July to September 2018

FSW reached FSW tested HIV positive Case finding rate

1000 921 45.0% 40.5% 900 866 856 40.0% 792 800 35.0% 700 591 30.0% 24.8% 600 542 25.4% 25.0% 500 450 432 20.0% 400 15.6% 11.3% 312288 15.0% NumberFSWs of 300 7.3% 8.0% 158 FSWs of Percentage 200 5.1% 149 10.0% 63 63 61 62 59 100 45 37 40 5.0% 22 15 3715 0 0.0% less than 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 Greater or 20 years years years years years years years equal 50 years Age Range (Years)

Age disaggregation: Disaggregation by age shows that case finding generally increases with age. The highest HIV positivity rates were found among FSWs who were at least 50 years old (40.5 percent), followed by those 45-49 years old (25.4 percent) and 40-44 years old (24.8 percent). For FSWs younger than 20 years old, the case finding rate was 5.1 percent. The program will increase its focus on HIV case finding among older FSWs while continuing to provide comprehensive prevention and regular HIV testing to younger FSWs.

Figure 9. HIV testing and case finding among FSWs, Life of Project

FSW Tested for HIV FSW Tested HIV Positive % case finding 6655 7000 6421 12.0%

6000 10.1%10.0% 4819 5000 8.6% 4445 8.0% 7.6% 4189 4000 3466 3619 3452 3165 6.0% 5.6% 3000 2750 4.6% 4.8% 4.3% 4.4% 4.0% NumberFSWs of 2000

3.4% 3.4% Percentage of FSWs

1000 2.0% 321 264 275 120 163 123 304 203 250 296 0 0.0% FY16Q3 FY16Q4 FY17Q1 FY17Q2 FY17Q3 FY17Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 Quarter

Note: HIV case finding increased with the introduction of EPOA, self-testing and index testing.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 10 Figure 10. HIV testing and case finding among FSWs, FY18 1800 14.0% 1616 1600 12.5% 1450 1437 12.0% 1420 1409 1379 1400 1301 1208 10.1% 10.0% 1142 9.7% 1200 1102 9.1% 1036 8.4% 1000 8.0% 7.4% 800 6.4% 750 5.8% 6.0% 5.2% 5.1% NumberFSWs of 600 4.5% 4.2% 4.0% 400 2.0% 200 103 111 126 61 75 67 83 64 89 96 101 94 0 0.0%

FSW tested for HIV FSWs tested HIV-positive Case finding rate

Note: HIV case finding increased with the introduction of EPOA, self-testing and index testing.

Testing: LINKAGES met 88.7 percent of the quarterly testing target and exceeded the annual target by 107 percent. This result is due to the high percentage of reached KPs who were tested (93 percent). The project has successfully found many KPs who are eligible for testing through EPOA, self-testing, and index testing. During the upcoming fiscal year, the project will pay more attention to the appropriate utilization of risk assessments by PEs to better target and test only those at high-risk. The project will prioritize the “test less, find more” approach, based on USAID priorities.

Case finding: The rate of 10.4 percent is higher than the 7 percent rate for Q1-Q3 and an increase from the previous quarter (8.6 percent). The highest case finding rate was found in Kinshasa (11 percent) and Haut-Katanga (11 percent). The project reached its highest case finding rate to date in September 2018 (12.5 percent). This success is due to the implementation of index testing, HIVST, and the EPOA campaign. The appropriate use of the risk assessment tool will be reinforced to improve case finding in FY19.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 11 Figure 11. ART uptake among newly diagnosed FSWs in DRC, Life of Project

Tested HIV positive Newly initiated on treatment %ART

350 100.0% 321 304 83.3% 84.8% 87.8% 88.2% 81.6% 296 90.0% 300 275 283 264 260 80.0% 69.1% 250 250 74.2% 62.8% 70.0% 57.6% 73.2% 203 212 190 191 60.0% 200 163 169 152 50.0% 150 133 120 123 40.0%

NumberFSWs of 89 90 30.0% 100 FSWs of Percentage 20.0% 50 10.0% 0 0.0% FY16Q3 FY16Q4 FY17Q1 FY17Q2 FY17Q3 FY17Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 Quarter

Treatment: Of the 321 FSWs who newly tested positive, 283 (88 percent) were newly enrolled in care and started on ART. An overall upward trend in ART uptake was observed this quarter. In Kinshasa and Lualaba, a higher percentage of newly diagnosed FSWs started on ART (91 percent and 90 percent, respectively) than in Haut-Katanga (85 percent). LINKAGES will continue to focus its efforts on engaging existing clients in care through improved tracking in collaboration with health providers.

Figure 12. FSW prevention cascade, EPOA vs. traditional outreach in the three provinces, FY19 – July to September 2018 3500 12.0% 3,165 10.0% 10.7% 3000 10.0% 10.1% 2,574 2500 8.0% 2000 6.0% 1500 4.0%

NumberFSWs of 1000 Percentage Percentage of FSWs 591 2.0% 500 321 258 63 0 0.0% Total Traditional Outreach EPOA

FSWs tested for HIV FSWs tested HIV-positive Case finding rate

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 12 Figure 13. FSW treatment cascade, EPOA vs. traditional outreach in three provinces, FY18 – July to September 2018 350 100.0% 88.2%321 88.9% 90.0% 300 283 88.0% 258 80.0% 250 227 70.0%

60.0% 200 50.0% 150

40.0% NumberFSWs of

100 30.0% of Percentage FSWs 63 56 20.0% 50 10.0%

0 0.0% Total Traditional EPOA

FSWs tested HIV positive FSWs newly initiated on treatment % on ART

EPOA Campaign: All of the 591 FSWs who were reached were tested and received their results in Lualaba (166) and Haut-Katanga (362). The case finding rate was 10.7 percent with EPOA and 10 percent without EPOA. With appropriate utilization of the risk assessment tool, case finding improves through traditional outreach HTS. Of all the HIV-positive FSWs reached through EPOA, 88.9 percent were initiated on ART. Of all the HIV-positive FSWs reached through traditional outreach, 88 percent were initiated on ART. The team will continue to track those lost to follow-up and attempt to initiate them on treatment in the next fiscal year.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 13 Figure 14. HIV cascade services for Zambian FSWs at the cross-border sites in Sakania health zone within Haut-Katanga Province, FY18 FSW: Prevention part of the FSW: Treatment part of the cascade, FY18 cascade, FY18 900 880 140 83.4% 800 792 120 103 700 90 18.9% 100 600 169 17 167 76.5% 80 100% 500 13 13 55 26 400 247 60 50 50 226 24 24 300 26 NumberFSWs of 40 18 18 279 NumberFSWs of 200 250 20 100 29 25 25 - - FSWs reached FSWs tested for FSWs tested HIV- FSWs newly FSWs newly HIV postive enrolled in care enrolled in Prevention Indicators treatment FY18 Q1 Results FY18 Q2 Results Care and Treatment Indicators FY18 Q3 Results FY18 Q4 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Target FY18 Q4 Results FY18 Target

Cross-border: In Zambia, LINKAGES continued to work closely with the Open Doors Project (ODP) and its IP to serve mobile KPs along the corridor: 103 FSWs were reached this quarter; 90 FSWs were tested for HIV and received their results; 17 FSWs tested positive for HIV (18.9 percent case finding rate); and 13 FSWs were initiated on ART at health facilities (76.5 percent).

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 14 Clients of FSWs Cascade: Figure 15

Figure 15. HIV cascade for FSW clients in DRC, FY18 FSWs clients: Prevention part of the FSWs clients: Treatment and care cascade, FY18 part of the cascade, FY18 5,350 5,500 5,000 4,815 140 4,500 4,000 120 735 96 53 3,500 96.2% 707 7.5% 100 81.1% 100% 3,000 43 43 886 856 80 2,500 2,000 60 43 1,259 1,159 36 36

1,500 40 Number FSW of clients 1,000 Number FSW of clients 22 20 21 21 500 1,127 1,084 18 13 13 - - FSW clients reached FSW clients tested for HIV FSWS clients tested FSW clients newly FSW clients newly HIV-postive enrolled in care enrolled in Prevention Indicators treatment Care and Treatment Indicators FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target

Services to FSW Clients: Despite the fact that only 75% of the annual reach target for FSW clients was met, case finding significantly improved from Q3 (5%) to Q4 (7.5%). Of those who tested HIV-positive, 81.1 percent were enrolled in care and initiated on ART, compared to 84% in the previous quarter.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 15 MSM Cascades and Analyses: Figures 16 to 26 Summary: During this quarter, LINKAGES DRC reached 1,338 MSM, of which 1,077 (80.5 percent) received HTS and their results. Among them, 102 (9.5 percent) were HIV-positive and 87 (85.3 percent) were enrolled in care and initiated on ART. In Kinshasa, 84.8 percent of those who tested HIV-positive were initiated on ART, and in Haut-Katanga, 87 percent of those who tested HIV-positive started treatment. This overall success is the result of reinforced supervision and coaching of PEs and ORWs who supervise PEs, along with the community’s mobilization activities and close collaboration between PNs and health providers at the institutional level.

Figure 16. Cascade for MSM, FY18 MSM: Prevention part of MSM: Treatment part of the cascade, FY18

the cascade, FY18 300 12,000 273 11,000 10,628 246 246 250 100% 10,000 102 85.3% 9,000 200 8,000 87 87 7,000 80.5% 9.5% 150 62 6,000 5,000 1,338 55 55 3,890 1,077

NumberMSM of 100 Number MSM Number of 4,000 1,058 940 76 3,000 1,680 56 56 2,000 1,500 50

1,000 1,643 1,540 46 36 36 - - MSM reached MSM tested for MSM tested HIV- MSM newly MSM newly HIV postive enrolled in care enrolled in Prevention Indicators Care and Treatment Indicators treatment FY18 Q1 Results FY18 Q2 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q3 Results FY18 Q4 Results FY18 Q4 Results FY18 Target FY18 Target

Reach: Almost 94 percent of the quarterly reach target was met, and LINKAGES exceeded the annual reach target by 147 percent. This success is due to joint efforts by the LINKAGES national team, IPs, and MSM PEs. The EPOA campaign also contributed to case finding, representing 8 percent of those reached in Q4. Quarterly and annual targets were met in Kinshasa (1,028 cases) and Lualaba (310 cases).

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 16

Figure 17. Treatment part of cascade: VL testing & suppression among HIV-positive MSM, Life of Project 400 360 350 339

300 94.2% 250 46.9%

200 159 52.8% 46.4% 150 82.1%

100 84 39 Numer of Numer of MSM 50 32

0 MSM tested MSM initiated MSM eligible for MSM tested for MSM VL results MSM with VL HIV-positive on ART VL testing VL received suppressed Care and Treatment indicators

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 17 Figure 18. HIV prevention cascade for MSM in Kinshasa, Haut-Katanga, and Lualaba provinces, FY18 MSM: Prevention part of the MSM: Prevention part of the cascade, MSM: Prevention part of the cascade, cascade, FY18 FY18 FY18 Kinshasa Haut-Katanga Lualaba 5,349 3,000 2,600 2,576

2,703 5,000 2,400

2,500 2,200

2,000 4,000 1,028 83.2% 2,000 1,800 855 1,600 3,000 2,800 806 1,400 739 1,500

1,200 NumberMSM of NumberMSM of 310 71.6%

1,000 NumberMSM of 2,000 1,000 1,287 1,000 1,179 228 222 185 800 357 600 1,000 500 296 1,163 1,147 400 16 456 24 382 25 200 36 - - 90 24 11 MSM Reached MSM tested for HIV MSM Reached MSM tested for HIV - Prevention indicator Prevention indicator MSM Reached MSM tested for HIV Prevention indicator FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target FY18 Q3 Results FY18 Target

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 18

Figure 19. HIV case finding for MSM in Kinshasa, Haut-Katanga, and Lualaba provinces, FY18 Kinshasa MSM: HIV case finding, Haut-Katanga MSM: HIV case Lualaba MSM: HIV case finding, FY18 finding, FY18 FY18 1400 10.0% 450 12.0% 30 9.0% 9.2%

1179 9.0% 400 382 10.4% 8.0% 8.0% 1200 1147 25 10.0% 25 8.0% 7.7% 350 7.0% 1000 7.0% 296 300 8.0% 20 6.0% 5.8% 855 6.0% 800 739 250 222 5.0% 5.0% 6.0% 15 200 185 600 4.0%

4.0% 11

NumberMSM of NumberMSM of NumberMSM of 3.7% 150 4.0% 10 3.0% 400 3.0% 100 2.7% 2.0% 2.0% 5 2.0% 2.0% 5 200 50 2 1.0% 68 57 79 1.0% 1.0% 23 42 6 5 4 0 0 0 0 0 0.0% 0 0.0% 0 0.0% 0.0% 0.0% FY18 Q1 FY18 Q2 FY18 Q3 FY18 Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 HIV Testing Indicators HIV Testing Indicators HIV Testing Indicators

MSM tested for HIV MSM tested HIV-positive MSM tested for HIV MSM tested HIV Positive MSM tested for HIV MSM tested HIV-positive Case finding rate Case finding rate Case finding rate

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 19 Figure 20. Care and Treatment Cascade for MSM in Kinshasa, Haut-Katanga and Lualaba provinces, FY18

Kinshasa, MSM: Treatment part of the Haut-Katanga, MSM: Treatment part of Lualaba, MSM: Treatment part of the cascade, FY18 the cascade, FY18 cascade, FY18 250 80 70 74 85 % 61 70 60 79 200 100% 60 50 67 67 50 150 138 57 40 40 50 50 30

100

Numbeof MSM NumberMSM of

NumberMSM of 30 87% 68 23 20 100% 20 20 50 50 20 50 5 10 5 5 10 42 6 4 4 32 32 2 2 2 4 4 4 ------MSM tested Newly Enrolled Newly Enrolled MSM tested Newly Enrolled Newly Enrolled MSM tested Newly Enrolled Newly Enrolled HIV-postive in care in treatment HIV-postive in care in treatment HIV-postive in care in treatment Care and Treatment Care and Treatment Care and Treatment FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q3 Results FY18 Q1 Results FY18 Q2 Results FY18 Q4 Results FY18 Target FY18 Q4 Results FY18 Target FY18 Q3 Results FY18 Target

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 20 Figure 21. HIV positivity by age among MSM in DRC, FY18 – July to September 2018

500 458 50.0% 450 46.2%45.0%

400 373 359 40.0% 350 34.4% 35.0% 300 276 30.0% 250 25.0% 190 200 165 20.0% 163 18.7% 18.2%

NumberMSM of 150 132 15.0% 10.1% 12.1%93 Percentage of MSM 100 75 10.0% 4.5% 4.0% 43 50 28 20 32 17 5.0% 6 15 14 11 1511 2 13 6 0 0.0% less than 20 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 Greater or years years years years years years years equal 50 years Age Range (Years)

MSM reached MSM tested HIV positive % Yield

Age Disaggregation: Disaggregation by age shows that HIV case finding rates generally increase with age. The highest HIV positivity rates were found among MSM who were at least 50 years old (46.2 percent), followed by those 40-44 years old (34.4 percent). For MSM younger than 20 years old, the case finding rate was 4.5 percent. The program will increase its focus on HIV case finding among older MSM while continuing to provide comprehensive prevention services and HIV testing to younger MSM.

Figure 22. HIV testing and case finding among MSM in DRC, Life of Project

MSM Tested for HIV MSM Tested HIV Positive Case Finding Rates

2077 10.0% 9.5% 2000 1914 9.0% 8.0% 1540 1500 1500 7.0% 1280 6.6% 6.0% 1077 994 995 5.1%940 5.0% 1000 4.0% 3.7%

NumberMSM of 3.0% 3.0% 2.7% 2.9% 2.7% Percentage of MSM 500 411 2.0% 1.3% 77 76 102 1.0% 11 29 170.9% 13 35 46 62 0 0.0% FY16Q3 FY16Q4 FY17Q1 FY17Q2 FY17Q3 FY17Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 Quarter

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 21 Figure 23. HIV testing and case finding among MSM in DRC, FY18 – October 2017 to September 2018 700 14.0% 636

600 12.3% 12.0% 534 507 494 500 472 9.9% 10.0% 420 397 400 374 8.0% 6.7% 316 329 6.6295% 6.8% 283 6.7% 300 6.0%

5.2% Percentage 4.9% 5.1% NumberMSM of 200 4.0% 3.6% 2.8% 2.7% 100 46 2.0% 11 17 18 23 25 28 21 20 22 28 28 0 0.0%

MSM tested for HIV MSM tested HIV-positive Case finding rate

Note: HIV case finding increased with the introduction of EPOA, self-testing, and index testing

Testing: Of those reached, 80.5 percent were tested for HIV. The number of MSM tested against the LINKAGES USAID target was 94 percent of the target for the quarter and 47.6 percent of the yearly target. This is due to testing targets being higher than reach targets.

Case finding: Case finding among MSM for Q4 was 9.5 percent, which is an increase from the previous quarter (6.6 percent). The highest case finding rate was found in Haut-Katanga (10 percent), followed by Kinshasa (9 percent). There were no cases found in Lualaba. Case finding through the EPOA campaign was reported to be 12.6 percent, demonstrating the success of this approach compared to Q3 results (6.6 percent). This is thanks to efforts made by all IPs and the LINKAGES team, as well as the index testing and self-testing approaches used this reporting period.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 22 Figure 24. ART uptake among newly diagnosed MSM in DRC, Life of Project

MSM Tested HIV positive MSM Newly initiated on treatment %ART

120 100.0% 88.7% 102 90.0% 85.3% 100 78.3% 77.1% 87 80.0% 75.9% 73.7% 77 70.0% 80 76 61.5% 60.0% 58.8% 62 60 56 55 50.0% 46.8% 46 40.0% 36.4% 36 35 36

NumberMSM of 40 29 27 30.0%

22 Percentage of MSM 17 20.0% 20 13 11 10 8 4 10.0% 0 0.0% FY16Q3 FY16Q4 FY17Q1 FY17Q2 FY17Q3 FY17Q4 FY18Q1 FY18Q2 FY18Q3 FY18Q4 Quarter

Treatment: Eighty-seven (85.3 percent) of the 102 MSM who tested positive were enrolled in care and initiated on ART. Many of the HIV-positive MSM were identified near the end of the quarter and were not yet linked to care by the end of Q4, but we noted a good upward trend this quarter. In the next fiscal year, LINKAGES will focus on ensuring that these identified MSM start on treatment in FY19 Q1 and are not lost to follow-up. The team is currently engaged in discussions on potential collaboration with an MSM-led organization and working with an MSM-friendly doctor.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 23 Figure 25. HIV prevention cascade services for MSM with EPOA campaign and traditional outreach in Haut- Katanga and Lualaba provinces, FY18 - July to September 2018 1200 14.0% 1,077 12.6% 974 12.0% 1000

9.1% 10.0% 800 9.5% 8.0% 600

6.0% Percent MSM of Percent NumberMSM of 400 4.0%

200 102 89 103 2.0% 13 0 0.0% Total Traditional Outreach EPOA

MSM tested for HIV MSM tested HIV-positive Case finding rate

Figure 26. HIV treatment cascade services for MSM with EPOA campaign and traditional outreach in Haut- Katanga and Lualaba provinces, FY18 – July to September 2018 120 85.6%

102 85.4% 100 85.3% 87 85.4% 89 85.2% 80 76

85.0% 60

84.8% Percent Percent MSM of NumberMSM of 40 84.6% 84.6%

20 13 11 84.4%

0 84.2% Total Traditional EPOA

MSM tested HIV-positive MSM newly initiated on treatment % on ART

EPOA campaign: The case finding rate was 12.6 percent with EPOA and 9.1 percent without EPOA in Haut-Katanga and Lualaba. The percentage of HIV-positive cases who initiated treatment through EPOA was 84.6 percent. Of all the HIV-positive MSM reached through traditional outreach, 85.4 percent were

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 24 initiated on ART. Only Haut-Katanga reached MSM with EPOA in Q4. The overall MSM case finding rate for LINKAGES DRC (through EPOA and traditional outreach) is 9.5 percent. This case finding rate increased thanks to the implementation of the EPOA campaign.

Result Area 2: Demand for comprehensive prevention, care, and treatment services among FSWs and MSM enhanced and sustained.

• Information Communication Technology (ICT) activities: Identifying and reaching new MSM for HIV testing and STI diagnosis and treatment, immediately linking those who test positive to ART and care, and retaining them in treatment requires dynamic and creative approaches in both clinical and community settings. This is especially true for MSM who are reluctant to access services for a variety of reasons, including stigma and discrimination issues. In line with our FY18 work plan, LINKAGES initiated implementation of ICT in Q4, particularly in Kinshasa, to increase reach and recruitment of hard-to-reach MSM. The first step of implementation was completed, and 20 MSM were trained on the approach. With the continued support of TOM+ funds in the upcoming quarter, TA will be provided to develop various online messages (adapted to the DRC context), implement the online risk assessment tool, and support related activities for Peer Educators Online (PEO). The monitoring and evaluation (M&E) system was adapted for adequate reporting, and data will be available at the beginning of FY19.

• Economic strengthening activities through the group loan saving approach (GLSA): LINKAGES DRC continued to strengthen mobilization and empowerment of KPs through economic strengthening activities. These activities were conducted in DICs and in the community, providing additional opportunities for regular contacts with KP. During the sessions, key HIV prevention messages and services, including condoms distribution, HTS, messages on the importance of VL testing, and advice on low-risk behaviors, was provided. During Q4, LINKAGES DRC organized 19 GLSA groups. The total funds saved in this period was US$10,788 (17,261,000 CDF), and three groups distributed US$3,212 (5,141,500 CDF) of saved funds in Kinshasa and Haut-Katanga.

• Reinforcement of KP-led associations in Haut-Katanga: LINKAGES DRC continued to support two local KP-led organizations: AMAP (Apprends-Moi à pêcher/Teach Me to Fish) and VAG (Vision of the Eagle; Vision de l’Aigle). Both associations benefited from a capacity-building training of board members on planning aspects and project management. During this workshop, the participants learned how to write and manage a budget, how to develop a work plan, and how to share responsibilities within their respective organization. In total, 16 people took part in the workshop, including 8 FSWs and 8 MSM.

• Official launch of new building for DIC (PSSP 2): This event was an opportunity to increase awareness on the new location of the DIC (run by PSSP 2) among MSM, and to promote utilization of services offered. A total 45 MSM were reached during this event, and 6 MSM were tested and were negative. This event was also attended by Bandalungwa politico-administrative authorities.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 25 Result Area 3: Strengthened systems for planning, monitoring, evaluating, and assuring the quality of programs for FSWs and MSM.

• Conducted regular data review meetings with stakeholders: On a monthly basis, IPs have organized data analysis meetings for certification and validation of data with community workers and health care providers. During Q4, 18 monthly meetings were held among all LINKAGES IPs. Key points discussed included the need for collaborative action to ensure improvement of VL testing data for all eligible HIV-positive KPs enrolled in LINKAGES-affiliated health institutions and the best way to maximize support from TOM + funds (e.g., recruit additional PNs to improve follow-up/track those lost to follow-up).

• Conducted hot spot validation exercise in Haut-Katanga: LINKAGES DRC organized the map and size estimation exercise in two additional zones where activities will be implemented in FY19: Rwashi and Kampemba. The exercise began with the identification and validation of hot spots in both health zones, in order to collect basic data to plan activities, particularly microplanning. The preliminary results are summarized in Table 1.

Table 1. Hot spot size estimation exercise results in Kampemba and Rwashi Health Zone Number of Hot Spots KP Size Estimation (not adjusted) KAMPEMBA 21 383 RWASHI 24 471 TOTAL 45 854

• Disseminated PLACE report and hot spot validation results: During the quarterly KP technical working group meeting in August, which took place in Kinshasa under the leadership of PNLS, the results of the PLACE report and FY18 hot spot validation exercise were presented by LINKAGES and UNC. In total, 43 people participated in the meeting, all of whom represented PEPFAR’s IPs working with KPs, including ICAP, EGPAF, LINKAGES, and Global Fund-supported IPs working with KPs. The HIV national program staff from PNLS and all chief medical officers of the health zones covered by LINKAGES were also in attendance. Attendees actively participated in the presentation and discussion. Results of the PLACE report were presented by a UNC consultant, followed by presentation of the results of the hot spot validation by the LINKAGES technical coordinator and M&E manager. This exercise was conducted in order to update hot spots and size estimations of KPs using both the results from the PLACE study and the sites routinely frequented by peer educators. In total, 1,061 sites were validated, including 974 hot spots frequented only by FSWs, 8 frequented only by MSM, and 79 frequented by both groups. KP size estimates are as follows: 9,325 for FSWs and 563 for MSM. Recommendations were made at the quarterly KP technical group meeting to regularly update hot spots.

• Continued collaboration with other USAID IPs: In September 2018, a memorandum of understanding (MOU) for the upcoming year was renewed between LINKAGES and ELIKIA to benefit orphans and vulnerable children. The MOU was renewed with the objective of ensuring a continuum of care for KPs through a referral mechanism and counter-referral between clinical services and community-based HIV/AIDS prevention and care services, implemented by LINKAGES DRC in collaboration with the Integrated Health HIV AIDS Project (IHAP).

• Collaborated with national and regional HIV stakeholders: Activities included:

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 26 - Monthly sub-working group meetings to discuss ART and STI drugs. The goal of these meetings was to see how Chemonics, a USAID partner in charge of supply chain, can continue to make commodities available to IPs. - Data analysis and presentation meeting organized by the Lualaba Division of Health. All data for each health sector have been presented by Division of Health staff members and some IPs. LINKAGES Lualaba also presented project achievements. - Preparatory work session to plan the integrated biological and behavioral survey conducted by CDC and the School of Health. LINKAGES and ICAP were identified as leading organizations for KPs for this upcoming exercise (to be done in FY19).

• Conducted trainings under TOM+ funds for IPs, PEs, PNs, and ORWS to improve the scope and efficacy of services offered, including: - Training for 192 participants on the correct use of the risk assessment tool. - Training for 21 PEs/PNs in Lualaba on HTS sessions. - Training on ICT. - Training for 30 health care providers and workers on how to provide high-quality HIV services to KPs. - Training for 195 participants (123 community workers, 31 health care providers, and 41 IP staff members) in Kinshasa (107 participants), Haut-Katanga (46 participants), and Lualaba (42 participants) on index testing and HIVST. - Training for 40 participants (HIV case managers, HTS counselors, nurses, and PNs) to improve motivational interviewing.

3. Crosscutting Issues

• VPR groups and case monitoring: In Q4, six VPR groups were fully functional (four in Haut- Katanga and two in Lualaba). In Kinshasa, PSSP has a VPR focal point. Eighteen meetings were organized, and 20 cases of violence (18 against FSWs and 2 against MSM) were reported and documented. Of these cases, 14 occurred in Lualaba, and attackers were frequently recorded as truck drivers, policemen, and artisanal miners. Medical, psychosocial, and legal support for victims of violence was provided for all cases.

4. Management and Operations

• Operations and staffing: The LINKAGES office in Lualaba was closed to reduce project costs. The FHI360/LINKAGES site coordinator for Lualaba province remains, but will be supported by Maison Faradja, a LINKAGES IP. • Subawards: Jeunialissime was approved by USAID as a new IP for LINKAGES in Kinshasa, with a focus on MSM. LINKAGES initiated FY19 modifications for all IPs. • Pact community mobilization activities ended at the end of Q4 due to budget constraints. Community mobilization activities will now be handled by IPs’ staff in all provinces. • FY19 work plan and budget: Both were submitted to USAID DRC in September. The budget for FY19 is not sufficient to continue ongoing activities and reach allocated targets. LINKAGES is counting on additional TOM+ funds to cover certain costs, including TA and implementation support for key initiatives (e.g., EPOA, Going Online, HIVST).

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 27 5. Quarterly Financial Summary Expenditures this Total Obligation Obligation Quarter Expenditures Remaining $ 7,651,818 $ 723,269 $ 7,637,317 $ 14,501

6. Major Activities Next Three Months (October to December 2018) During the next three months, LINKAGES DRC will: • Disseminate the final report from the mapping and size estimation exercise in two health zones (Rwashi and Kampemba) • Initiate LINKAGES activities in two additional health zones (Rwashi and Kampemba) • Complete ICT implementation in Kinshasa (i.e., develop key online messages and online risk assessment tool) • Develop DH2 data system • Continue EPOA campaigns • Continue index testing and self-testing at all sites to improve case findings • Continue follow-up of VL testing for eligible KPs at all sites • Assist VAG, the MSM-led organization in Lubumbashi, with proposal preparation in response to a call for proposals from the International LGBTI Fund • Contribute to the KP task force in quarterly meetings led by PNLS • Actively participate in World AIDS Day (Dec 1st) • Provide continuous TA to IPs and closely monitor all subawards

7. Kudos During the reporting period, LINKAGES DRC greatly appreciated the work done by MSM PEs who were able to use HIVST to reach hidden peers. One MSM PE from PSSP 2, who was trained on HIVST and how to properly use the risk assessment tool, was very happy to provide (and assist with the use of) nine self-testing kits to nine of his peers. These MSM are his friends who had refused to be tested because of fears of injections and of stigma in health facilities and DICs that offer HIV prevention services. Four of the kits were reactive, all of which were confirmed positive, and the MSM were initiated on ART. Without HIVST, these four MSM would never have been aware of their HIV-positive status and would never have started ART. The contribution this PE made to the well- being of his reluctant peers is a great accomplishment.

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 28 8. Visuals

Capacity building of LINKAGES DRC staff with TOM+ funds

Index Testing Training

HIVST Training

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 29 Implementation of the CSDP in Kasumbalessa within Haut-Katanga

Jeunialissime starts activities in Kinshasa

VPR in action in Kolwezi, supporting KP victims

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 30

Internal data analysis meeting with the LINKAGES/Lualaba site coordinator before the monthly data certification meeting with all stakeholders

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 31 Annex A: Performance M&E Matrix

Achievements/Targets Indicators (PEPFAR) PEPFAR FSWs MSM FSW clients Support % target % Target % Target Year to Annual Year to Annual Year to Annual Type Q4 achieved Q4 Achieved Q4 Achieved Date Target Date Target Date Target to date to Date to Date KP_PREV: Number of KPs reached with individual or small group-level - - - - DSD 3,390 16,263 12,500 130,1% 1,338 5,719 3,890 147.0% HIV prevention interventions designed for the target population PP_PREV: Number of “priority population/clients of FSWs" who completed a standardized HIV prevention intervention DSD ------735 3,897 5,350 72.8% including the specified minimum components during the reporting period (PEPFAR) HTC_TST: Number of KPs who received HTC services for HIV DSD 3,165 15,250 14,276 106,8% 1,077 5,057 10,628 47.6% 707 3,781 4,815 78.5% and received their test results HTC_TST_POS: Number of KPs who tested HIV-positive DSD 321 1,070 569 188.0% 102 286 273 104.8% 53 136 96 141.7% TX_NEW: Number of KPs newly enrolled on ART TA 283 924 512 180.5% 87 234 246 95.1% 43 113 NA NA CARE_NEW: Number of HIV-positive KPs newly enrolled in clinical care during the reporting period who received at least TA 283 924 512 180.5% 87 234 246 95.1% one of the following at enrollment: clinical assessment - - - - (World Health Organization staging) OR CD4 count OR VL

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 32

Achievements/Targets Indicators (CUSTOM) PEPFAR FSWs MSM Support Year % Target Year % Target Annual Annual Type Q4 to Achieved Q4 to Achieved Target Target Date to Date Date to Date TX_LINK_NEW: Number of KPs newly diagnosed with HIV who were successfully navigated/supported TA 283 924 TBD N/A 87 234 TBD N/A to enroll into a treatment program TX_PVLS: Number of adult and pediatric patients on ART with suppressed VL results (<1,000 copies/ml) documented in the medical records or supporting laboratory results within the TA 120 120 TBD - - 32 TBD TBD past 12 months TX_LINK_RETURN: Number of KPs who were previously diagnosed with HIV (knew they were HIV- positive) but are not currently receiving ART and were successfully navigated/supported to enroll into TA 0 20 TBD N/A 0 0 TBD N/A a treatment program by LINKAGES COMM_SUP_RET: Number of HIV-positive KPs newly enrolled for care and support outside of the DSD 283 924 TBD N/A 87 234 TBD N/A health facility Number of Zambian KPs reached in DRC via cross-border activities DSD 103 629 NA - - - - - Number of Zambian KPs tested for HIV and received their results in DRC via cross-border activities DSD 90 566 NA - - - - -

Number of Zambian KPs tested positive for HIV via cross-border activities DSD 17 72 NA - - - - -

Number of Zambian KPs tested positive for HIV in DRC and initiated on TARV TA 13 53 NA - - - - -

Achievements Indicators (Program) PEPFAR Support Type Annual Target % Target Achieved Q4 Year to Date Number of PEs and PNs re-trained in BCC and M&E tools DSD 0 200 200 100% Number of community workers re-trained in BCC and M&E tools DSD 0 136 200 68,0% Number of local authorities trained on VPR/human rights TA 0 80 NA - Number of male condoms distributed through community workers DSD 299,452 1,310,137 TBD - Number of female condoms distributed through community workers DSD 34,822 164,374 TBD - Number of lubricant packs distributed through community workers DSD 21,206 87,857 TBD - Number of FSWs screened and treated for STIs at the DIC DSD 313 2,227 NA - Number of MSM screened and treated for STIs at the DIC DSD 35 931 NA - Number of FSW partners screened and treated for STIs at the DIC DSD 36 316 NA - Number of FSWs and MSM receiving ART refills at the points of distribution DSD 110 110 NA - Number of FSW and MSM cases reported and addressed for violence DSD 20 116 NA NA

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 33 Annex B: PERFOMANCE OVERVIEW FOR FY18

FSW PERFOMANCE OVERVIEW FOR FY18

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 34 MSM PERFOMANCE OVERVIEW FOR FY18

LINKAGES Quarterly Report (July 1 – September 30, 2018) - DRC 35