Zimbabwe HIV Care & Treatment Project

FY17: Q3 PROGRESS REPORT

Cooperative Agreement Number: AID-613-A-00009 A PRIL 1 – J UNE 3 0 , 2 0 1 7

Prepared for: Dr Tendai Nyagura, AOR

Submitted by: Donald Harbick, Chief of Party Family Health International (FHI 360) 65 Whitwell Road, Borrowdale West| |

This report was prepared with funds provided by the U.S. Agency for International Development under Cooperative Agreement No. AID-613-A-00009. The contents of this report are the sole responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.

April 1 – June, 30 2017 | FY17 Q3 Progress Report

Table of Contents

FY17 Q3 RESULTS ...... 6

1. INTRODUCTION ...... 7

2. Q3 RESULTS AND ACHIEVEMENTS ...... 7

HIV Testing Services ...... 7

Symptom screening ...... 11

Defaulter tracking ...... 11

PLHIV receiving ARVs through CARG ...... 12

Quality assurance for household index testing ...... 12

3. PERFORMANCE INDICATOR SUMMARY ...... 13

4. LABORATORY SERVICES STRENGTHENING ...... 14

5. MONITORING AND EVALUATION ...... 14

Site support and supervision ...... 14

Knowledge Management ...... 14

Database Systems ...... 14

6. FHI 360 Q4 PRIORITIES ...... 14

April 1 – June, 30 2017 | FY17 Q3 Progress Report 3

Table of Figures Figure 1: ZHCT HIV Testing Cascade ...... 8 Figure 2: District Performance ...... 8 Figure 3: HIV Services by Age Category ...... 9 Figure 4: HIV cascade for clients aged 20 - 30 years ...... 10 Figure 5: HTS_TST_POS performance by month ...... 10 Figure 6: ART defaulter tracking ...... 11 Figure 7: PT results for FHI 360 nurse testers ...... 13 Figure 8: VL testing at labs supported by FHI 360 ...... 14

List of Tables Table 1: TB symptom screening ...... 11 Table 2: CARGs (March 2016 to March 2017) ...... 12 Table 3: Q3 indicator performance table: April 1- June 30, 2017 ...... 13

Cover Photos Top: Outreach Workers at a refresher training in . Credits, Sibochiwe Manase, FHI 360 Chipinge District Team Leader Bottom: Female CARG members awaiting VL specimen collection in district. Credits, Elizabeth Tauya, FHI 360 Team Leader

April 1 – June, 30 2017 | FY17 Q3 Progress Report

List of Acronyms APHL Association of Public Health Laboratories AR&P Annual Review and Planning ART Antiretroviral Therapy ARVs Antiretroviral medicine AWP Annual Workplan CARG Community ART Refill Group CATS Community Adolescent Treatment Supporters CHO Community Health Officers COP Country Operational Plan CPF Community Program Facilitator DATIM Data for Accountability, Transparency and Impact DREAMS Determined Resilient Empowered AIDS-Free Mentored and Safe DCT Data Collection Tool DHIS2 District Health Information System version 2 DMO District Medical Officer EQA External Quality Assurance FHI 360 Family Health International 360 GOZ Government of Zimbabwe HTS HIV Testing Services LTFU lost to follow up MOHCC Ministry of Health and Child Care OW Outreach Worker PEPFAR President’s Emergency Plan for AIDS Relief PMD Provincial Medical Director PMP Performance Monitoring Plan PLHIV Persons Living with HIV PSI Population Services International QA Quality Assurance SOP Standard Operating Procedures UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development VL Viral Load ZHCT Zimbabwe HIV Care and Treatment Project

April 1 – June, 30 2017 | FY17 Q3 Progress Report 5

FY17 Q3 RESULTS

39% 47 11 Yield Rate People tested for HIV and received their results

40% 1854 FHI 360 progress towards HTS_POS COP16 Target Newly identified people living with HIV

98% 1338 ART initiation rate People living with HIV enrolled into 100% care TB screening of all new HIV positive clients 1306

People living with HIV initiated on ART

72% 97% Enrolment rate CARG members with suppressed viral load

100%

Proficiency Test rate amongApril nurse 1 – June testers, 30 201 7 | FY17 Q3 Progress Report

1. INTRODUCTION This report reviews progress made by FHI 360 during the quarter three of FY17 (April 1 – June 30, 2017) in implementing the USAID funded five-year Zimbabwe HIV Care and Treatment (ZHCT) project. The ZHCT project complements FHI 360 implements the ZHCT project the government of Zimbabwe (GOZ)’s efforts to strengthen as the prime partner in partnership with health facility and community linkages for HIV care and Plan International as the sub-awardee. treatment services provision. The goal of the project is to increase the availability and quality of comprehensive care and treatment services for persons living with HIV (PLHIV), primarily through community-based interventions. The ZHCT project accomplishes its overall goal by meeting the following specific objectives:- a) To increase the availability of quality comprehensive care and treatment services for HIV- positives at community level; through community-based household index testing with linkage to care and symptom screening including TB screening with referral. b) To strengthen community-level health systems to monitor, track and retain persons living with HIV (PLHIV) in care through ART defaulter identification and tracking, and adherence support for PLHIV through formation of CARGs. The ZHCT project is a comprehensive community-based intervention designed to provide sustained linkages between the community and health facilities. ZHCT will contribute towards Zimbabwe’s attainment of the first and the third 90s of the UNAIDS 90-90-90 Strategy. At the end of May 2017, FHI 360 received an additional obligation of US$1 million to support recruitment of additional locum nurses and improve mobility in the field through procurement of four hard-top vehicles suitable for the rough terrain in some districts. During the period under review, the ZHCT project was implemented in ten districts across three provinces (Midlands, and Manicaland). Plan International, with FHI 360 technical oversight, is implementing ZHCT activities in .

2. Q3 RESULTS AND ACHIEVEMENTS This section presents a summary of the key highlights from the ZHCT project from April 1to June 30 2017. HIV Testing Services A total of 4711 people were tested for HIV resulting in 1854 being newly identified as HIV positive. This is a yield rate of 39% (1854/4711) as shown in Figure 1 below. The project achieved 49% (1854/3815) on HTS_Pos against the quarterly target and 40% (6078/15262) against the annual target. The project has started combining testing modalities so that more individuals are tested in order to identify the remaining PLHIV who do not know their status.

April 1 – June, 30 2017 | FY17 Q3 Progress Report 7

Figure 1: ZHCT HIV Testing Cascade

Of the newly identified HIV positives, 72% (1338/1854) were linked to care (enrolled in pre-ART register). The linkage rate in Chipinge improved from 40% reported during the semi-annual period to 84% (133/159) achieved in the period under review as shown in Figure 2 below. This is attributed to the development of a linkage database which has allowed FHI 360 to retrospectively track newly diagnosed PLHIV for linkage into care. This database is also being utilized in all the project implementation districts in order to improve enrolment in care of the newly identified HIV positive clients. Other contributing factors include coordinated supervision of Outreach Workers, community sensitization on the importance of early ART initiation and the intensified use of project data. Figure 2: Chipinge District Performance on HTS Chipinge: HTS_Pos, Enrolment and Linkage

62 59 57 55 51 47 47 46 40 42

28 Number of clients clients of Number 13

1 JANUARY FEBRUARY MARCH APRIL MAY JUNE HTS_Pos Enrolment Initiated on ART Month-2017

April 1 – June, 30 2017 | FY17 Q3 Progress Report

During the reporting period, the majority (65%) [3062/4739] and 70% (1310/1866) of clients tested for HIV and diagnosed HIV positive respectively were aged 25-49 years as shown in Figure 3. This is consistent with the approach which mainly targets the sexually active (sexual partners of index cases) and also findings from other HIV testing modalities. However, the reach for males (46%) is much higher in the ZHCT project compared to other modalities which ranges from 25-33%1. This high reach to males is attributed to flexible working hours, good counseling skills and a deliberate strategy targeting men. Figure 3: HIV Services by Age Category

HIV Testing by Age Category

HTS_Tes HTS_Pos

4000

3000

2000

1000

Numberclients of 0 <10yrs 10-14 yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+ yrs Age categories

The ZHCT project is being implemented in four of the six DREAMS districts (Makoni, , and Chipinge). Even though, the target population for DREAMS is 10 -24 years, a disaggregation of data amongst the 20-30 age category indicates that yield and linkage rate was slightly higher among females as shown in Figure 4 below. The enrolment rate for males is encouraging as it shows that good counseling skills among the FHI 360 staff and efforts made by OW are working to ensure men who are generally known to have poor health seeking behavior are enrolled into care. This complements the support from DREAMS implementing partners.

1 Ministry of Health Program Data

April 1 – June, 30 2017 | FY17 Q3 Progress Report 9

Figure 4: HIV testing cascade for clients aged 20 - 30 years

Despite the high yield in the project, staff attrition continues to pause a challenge to the project. As highlighted in Figure 5 below, the decline in performance in April and May 2017 is attributed to staff attrition as nurse testers joined the MOHCC following the opening of about 2,000 posts and recruitment of qualified nurses to fill vacancies in public health facilities. This is set to continue as Nurse Testers prefer to join the MOHCC. To avert service interruption and address some of the challenges in the project, FHI 360 managed to recruit for some of the vacant positions in May and have broadened the scope of OWs including the introduction of a performance based incentive. In addition, all nurse testers were trained to ride a motorbike so as to improve mobility. The project has started working with other community based health workers such as Behavior Change Facilitators, Village Health Workers, Community HIV and AIDS Support Agents to increase the number of prepared index cases and linkage to care of newly diagnosed PLHIV. This is anticipated to significantly improve the monthly achievements in the remaining three months. All these community cadres will be under the supervision of a nurse tester managing a cluster of health facilities. Figure 5: HTS_TST_POS performance by month

1009

855 775 724

569 556 574 499 509

OCT-16 NOV-16 DEC-16 JAN-17 FEB-17 MAR-17 APR-17 MAY-17 JUN-17

April 1 – June, 30 2017 | FY17 Q3 Progress Report

Symptom screening All the 1854 newly diagnosed PLHIV were screened for TB of which 76% (1421/1854) were referred to health facilities for further TB management (Table 1). A referral completion rate of 76% (1083/1421) was achieved and twelve (1%) of these clients were confirmed to be TB positive and commenced on treatment. Table 1: TB symptom screening Male Female Total Tested for HIV 2163 2548 4711 HIV Positive 813 1041 1854 Screened for TB 813 1041 1854 Referrals for TB Management 636 785 1421 Successful Referrals for TB Management 508 575 1083 Positive TB Result 3 9 12

Defaulter tracking Figure 6 below indicates the defaulter tracking cascade with data on defaulters tracked and returned into care. The project continues to perform very well on keeping ART clients in care as 99% (1502/1514) of true defaulters were returned to care in this quarter. There was a significant number of clients 27% (569) who were registered as defaulters at the facility yet were still in care (confirmed to be still in care at the same facility (14%), self-transfer (10%) and official transfer (3%)). Efforts are being made to support facilities update ART registers. Figure 6: ART defaulter tracking

April 1 – June, 30 2017 | FY17 Q3 Progress Report 11

PLHIV receiving ARVs through CARGs The ZHCT project has a cumulative 864 functional CARG to date (192 were formed in Quarter 3), with a membership totaling 7180 (2483 male; 4697 female), as shown in table 2 below. Of the total membership, 11% (813/7180) had a documented valid viral load test result, of which, 93% (755) had a suppressed viral load (VL<1000 copies/ml). Of the 58 CARG members who had an unsuppressed viral load, 19 achieved suppression after 2 enhanced adherence counselling sessions while 13 were referred back to the health facility for close monitoring. The rest (26) were still awaiting a second viral load test. Table 2: CARGs (March 2016 to March 2017)

Number of Number of PLHIV receiving ARVs at community level functional District through refill groups Community ART Refill Groups Male Female Total 85 203 387 590 Chipinge 54 87 254 341 Makoni 149 497 948 1445 Mutare 124 381 813 1194 Mutasa 45 69 228 297 Gweru 130 342 649 991 Gokwe South 136 472 701 1173 Kwekwe 138 427 704 1131 Zaka 3 5 13 18 Total 864 2483 4697 7180

Quality assurance for household index testing The ZHCT project conducted several initiatives to ensure the quality of HIV testing at community levels. These included quality assurance focused SSVs, competency assessments, proficiency testing and refresher training during provincial review meetings. HIV testing quality assurance focused SSVs using the ZHCT QA checklist were conducted by various supervisors at various levels. Competency assessments for rapid HIV testing were conducted on all new Nurse Testers that joined the project in the period under review and for all fixed term Nurse Testers during the provincial review meetings held in May 2017. All 39 Nurse Testers participated in the national Round B of proficiency testing for rapid HIV testing that was conducted in May. Each Nurse Tester performed rapid HIV testing on a panel of the PT sample and all of them passed with 100%. Continued learning on HIV quality assurance was provided through quarterly review meetings and on-the-job trainings during SSVs.

April 1 – June, 30 2017 | FY17 Q3 Progress Report

Figure 7: PT results for FHI 360 Nurse Testers

FHI 360 Project Staff % Proficiency Testing Pass Rate 2016-2017 101% 100% 100% 99% 98% 97% 96% 96% 95% 94% Oct 2016 PT Round Apr 2017 PT Round

3. PERFORMANCE INDICATOR SUMMARY Table 3: Q3 indicator performance table: April 1- June 30, 2017 Q3 Performance Targets (April 1 – June 30, 2017) Reporting Indicators Deliverables Frequency COP16 Q3 Target Target Male Female Total (%)

1. Number of individuals who Number of receive HIV Testing and individuals tested Counselling (HTC) services for HIV and Quarterly 138250 34563 2163 2548 4711 14 for HIV and received their received results test results HTC_TST.

2. Percentage of clients testing Number of 39% HIV positive during the individuals 11 % Quarterly 3815 813 1041 49 reporting period diagnosed with HIV (15262) (1854 [HTC_TST_POS]. ) 3. Percentage of clients tested Clients tested for for HIV who were screened HIV screened for for TB symptoms at TB Symptoms Quarterly 100% 813 1041 1854 100 community level during the reporting period [customized] 4. Percentage of new PLHIV Number of new (from ZHCT) who were PLHIV enrolled into successfully enrolled into care Quarterly 90% 588 750 1338 72 care during reporting period [customized] 5. Percentage of ART defaulter Number of ART clients identified and defaulters successfully linked back to identified and Quarterly 85% 560 942 1502 99 care during the reporting linked to care period [customized]

April 1 – June, 30 2017 | FY17 Q3 Progress Report 13

4. LABORATORY SERVICES STRENGTHENING A total of 21360 viral load tests were conducted with support from the FHI 360 seconded staff at both Mutare and Gweru Provincial Hospital Laboratories. There was an increase in the total number of VL tests conducted with 41253 more tests from 17207 tests run in Q2. Lesser number of tests (40%) [8487/21360] were conducted at the Gweru laboratory compared to Mutare and this is attributed to the recurrent breakdown of the Roche machine experienced by this laboratory. Figure 8: VL testing at labs supported by FHI 360

VL Tests Conducted with FHI 360 staff

25000 21360 20000 17864 17207

15000 12873 9042 8822 9694 10000 7513 8487

5000

0 Oct-Dec 2016 Jan-Mar 2017 Apri-Jun 2017

Mutare Provincial Laboratory Gweru Provincial Laboratory Total VL Test

5. MONITORING AND EVALUATION Site support and supervision The project conducted site support visits in the 10 implementing districts for quality assessments, data validation and other site specific technical support, aimed at enhancing data quality. Knowledge Management Five abstracts were produced during the period under review of which two were accepted for poster presentation at the DHIS2 Oslo Conference and the other two for 2017 International AIDS Conference in Paris, France. The other abstract was accepted for oral presentation at the South Africa AIDS Conference. Database Systems In addition to the DHIS2, the project created a linkage database aimed at ensuring all newly diagnosed PLHIV are linked to care. This database will ensure timely follow up of all newly identified HIV positives in the ZHCT for enrolment in care and ART initiation.

6. FHI 360 Q4 PRIORITIES In order to improve performance and ramp up on targets in Q4, FHI 360 will implement the following strategies:- o Decentralisation of Nurse Testers to oversee a cluster of health facilities and supervising OWs and other identified community-based health cadres. o Distribute bicycles to improve mobility for OWs and produce IEC materials for greater visibility of FHI 360 work at community level.

April 1 – June, 30 2017 | FY17 Q3 Progress Report

o Roll out the performance based incentive scheme for OWs and other community based health workers to support the identification of index cases, linking newly identified positives to care as well as tracking of defaulters and bringing them back to care. FHI 360 will also increase collaboration with other partners such as OPHID and PSI to improve linkage to care and ART initiation. o Development and implementation of QI plans – focusing on HTS_POS and improve linkages o Implement other HIV testing modalities e.g. targeted outreach HIV testing in geographical hotspots and sub-populations, moonlight testing other HIV testing modalities in preparation for COP17. o Maintain the linkage to care database in all districts to closely follow up all newly identified HIV positives to ensure they are linked to care and initiated on ART o Community engagement through IEC materials & sensitization meetings for greater visibility of FHI 360 work at community level. In the upcoming Q4, FHI 360 will prioritize on COP 17 transition focusing on the following key activities:- o Development of COP17 Annual Work plan and Budget. o Management of Plan International close-out and FHI 360 transition into Masvingo province. o Plan for COP17 set up in new districts in Masvingo province (Chivi and Mwenezi).

o Sensitization of key stakeholders on CO17 transition.

April 1 – June, 30 2017 | FY17 Q3 Progress Report 15