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PROJECT SUMMARY Project Name:

Ending AIDS in West Africa Project (#EAWA); CA No. AID-624-A-17-00004 Life of Project (start and end dates): September 29, 2017 – September 28, 2022 Total Estimated USAID Amount: $16,500,000 Goal: Achieve HIV epidemic control in West Africa by accelerating progress across the region towards Ending AIDS through prevention, care and treatment, and accelerating of achievement of UNAIDS 90-90-90 targets with a focus on Key Populations and PLHIV Project Objectives: • Improve service delivery at community and health facility level • Strengthen the viral load laboratory system • Strengthen the monitoring and evaluation system

Prime Awardee: FHI 360 Project sub-awardees for FY20:

– 25 health facilities (20 DSD and 5 TA – SDI sites) in Togo – 17 health facilities (DSD sites) in Burkina Faso

Submission of Report Date: October 30, 2020

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TABLE OF CONTENTS

TABLE OF CONTENTS...... iii LIST OF ACRONYMS...... iv Section 1. Summary ...... 5 Section 2. Description of main results achieved ...... 10 Description of results achieved under the service delivery component ...... 10 HIV Prevention achievements ...... 10 HIV testing, linkage and ART initiation...... 14 Retention on ART and viral load suppression ...... 28 Full cascade of prevention, care and treatment ...... 36 Description of results achieved under the KPIF project ...... 38 Implementation of the Environmental Monitoring and Mitigation Plan (EMMP) ...... 41 Protecting Life in Global Health Assistance (PLGHA) ...... 41 Section 3. Discussion of challenges to implementation ...... 42 Monitoring of key assumptions...... 43 Section 4. Activities planned for next quarter ...... 44 Section 5. Financial brief ...... 45 1-Obligated amount ...... 45 2- Expenditures for Q4 FY20 and Cumulative Expenditures ...... 45 3- Subgrantees Disbursements (Q4 FY2020) and cumulative ...... 45 4- Next Quarter Projections (Q1 FY2021) ...... 45 5- Next Quarter Subgrantees Planned Disbursement (Q1 FY2021) ...... 45 Section 6. Summary of FY20 annual achievements ...... 46 Annual achievements on core indicators ...... 46 Trend of key indicators over the four quarters of FY20 ...... 47

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LIST OF ACRONYMS

ART Antiretroviral Therapy CCM Country Coordinating Mechanism COPCT Continuum of Prevention, Care and Treatment CSO Civil Society Organization DIC Drop-in Center EPOA Enhanced Peer Outreach Approach FHI 360 Family Health International FSW Female Sex Worker GBV Gender-Based Violence GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HIP High Impact Practice HTC HIV Testing and Counseling IPs Implementing Partners KP Key Populations KPIF Key Populations Investment Fund M&E Monitoring and Evaluation MoH Ministry of Health MSM Men Who Have Sex with Men NAC National Commission for the Fight against HIV/AIDS NGO Non-Governmental Organization PE Peer Educator PEPFAR The US President Emergency Plan for AIDS Relief PLHIV People Living with HIV PMP Performance Monitoring Plan PSSLS Programme Sectoriel Santé de Lutte contre le Sida et les IST RHO Regional Health Office RNR Risk Network Referral ROP Regional Operational Plan SBCC Strategic Behavior Change Communication SOP Standard Operating Procedures STI Sexually Transmitted Infections TA Technical Assistance UNAIDS Joint United Nations Program on HIV/AIDS USAID United States Agency for International Development USG United States Government VLS Viral Load Suppression

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Section 1. Summary The Ending Aids in West Africa (#EAWA) project is a five-year cooperative agreement between the United States Agency for International Development West Africa Mission (USAID/WA) and Family Health International (FHI 360). #EAWA was initiated with the goal of accelerating progress across the region towards Ending AIDS in West Africa through prevention, care and treatment, focusing on Key Populations to accelerate the achievement of UNAIDS 90-90-90 targets. From the second year of implementation of the #EAWA project (FY19), the US President Emergency Plan for AIDS Relief (PEPFAR), the main source of funding of #EAWA, undertook a major shift in programming in some West African countries. Because Togo and Burkina Faso have demonstrated the greatest progress nationally on the HIV clinical cascade, the PEPFAR West Africa Regional Operational Plan (ROP) 19, allocated additional funding to accelerate progress towards achieving the UNAIDS 95-95-95 goals. This funding was awarded through the Game Changer Fund to support the intensification of case finding strategies, linkage to care and retention, and viral load suppression (VLS), thus significantly improving their HIV/AIDS clinical cascades in two years (FY20 and FY21). With the Game changer funds, the project will go beyond KP programing and will target also general population. Therefore, the goal of #EAWA has evolved to: “achieve HIV epidemic control in West Africa by accelerating progress across the region towards Ending AIDS through prevention, care and treatment, and accelerating the achievement of UNAIDS 95-95-95 targets with a focus on Key Populations and PLHIV”. In this context, #EAWA oversees three components of the Game Changer strategy: (i) the service delivery component, (ii) the viral load laboratory system strengthening component, and (iii) the monitoring and evaluation component. With the service delivery component of the Game Changer funds, PEPFAR aims to reach nationally the first and second 90 in FY20 in Burkina Faso and Togo, and achieve the third 90 in FY21 through direct service delivery, with a targeted focus on the highest burden sites for PLHIV and KP (Centre, Hauts Bassins, and Centre Ouest Regions in Burkina Faso; Lomé Commune, Maritime, and Plateaux Regions in Togo), and with technical assistance to other sites. The Key Population (KP) program is also supported by the two-year (FY20/FY21) Key Populations Investment Fund (KPIF) via the Meeting Targets and Maintaining Epidemic Control (EpiC) project that is also led by FHI 360. This progress report depicts achievements and activities conducted during the fourth quarter of year 3 - period of July 1 to September 30, 2020 as part of the implementation of the #EAWA project. This report highlights also the achievements of the fourth quarter of implementation of the Game Changer Funds. It also highlights key achievements made over fiscal year 2020 – covering October 2019 to September 2020.

Summary of achievements on Key indicators • HIV prevention, testing, ART initiation, retention, and viral load suppression cascade During the fourth quarter of the fiscal year 2020, July 1 to September 30, 2020, a total of 8,221 individual key populations (3,851 MSM and 4,370 FSW) were reached with prevention interventions in both Togo (4,844) and Burkina Faso (3,377). 46,694 individuals (including 6,634 KPs) were tested for HIV and received their test results. Among those who received an HIV test, 5,142 individuals

5 (including 622 KPs) were newly diagnosed HIV positive (11% case finding). Among individuals newly diagnosed HIV positive, 4,957 (including 595 KPS) were newly enrolled on ART in the course of the quarter (96.4% ART linkage rate). The ART linkage rate in the two implementing countries is 96.4% (96.1% in Togo and 97.6% in Burkina Faso). The ART linkage rate is higher among female than male (96.9% vs 94.7% in Togo and 98.2% vs 96.1% in Burkina Faso). The table 1 below provides an overview of the cascade from the HIV testing to the viral load suppression in both countries during this quarter.

Table 1: Overview of the cascade of COPCT in Q4/FY20 HTS_TST HTS_TST_POS TX_NEW TX_CURR VL VL suppressed (yield) (%ART linkage) documented (TX_PVLS) Togo 36,439 3,988 (10.9%) 3,831 (96.1%) 32,808 13,531 11,186 (82.7%) Female 20,438 2,487 (12.2%) 2,409 (96.9%) 23,007 9,775 8,163 (83.5%) Male 16,001 1,501 (9.4%) 1,422 (94.7%) 9,801 3,756 3,023 (80.5%) Burkina Faso 10,255 1,154 (11.3%) 1,126 (97.6%) 25,483 2,015 1,562 (77.5%) Female 7,203 817 (11.3%) 802 (98.2%) 18,648 1,436 1,120 (78.0%) Male 3,052 337 (11.0%) 324 (96.1%) 6,835 579 442 (76.3%) Overall #EAWA 46,694 5,142 (11.0%) 4,957 (96.4%) 58,291 15,546 12,748 (82.0%) Female 27,641 3,304 (12.0%) 3,211 (97.2%) 41,655 11,211 9,283 (82.8%) Male 19,053 1,838 (9.6%) 1,746 (95.0%) 16,636 4,335 3,465 (79.9%)

As of September 30, 2020, the project recorded a TX_CURR of 58,291 ART patients receiving treatment including 32,808 ART patients in Togo and 25,483 ART patients in Burkina Faso. Compared to the annual target, the project has to date achieved 99.7% of the annual target of TX_CURR in Burkina Faso and 79% of the annual target in Togo. This gap in Togo is mainly explained by the fact that the initial value of TX_CURR was overestimated. Field data collected by #EAWA shows that the value of TX_CURR as of September 30, 2019 was 22,016 and not 29,265 as estimated by USAID, a difference of 7,249. Consequently, the target of TX_CURR as of September 30, 2020 was overestimated by 7,249. This target should therefore have been 34,297 and not 41,546 as assigned by USAID. If this had been the case, this target would have been reached at 95.7%.

The viral load data was extracted from the databases of the national electronic laboratory information system in both countries with a completeness of 100% in Togo and 47% (8 sites out of 17) in Burkina Faso. At the end of September 2020, viral load results were documented for 15,546 ART patients (13,531 patients in Togo and 2,015 patients in Burkina Faso). The VL coverage is 52% in Togo and 9% in Burkina Faso. The percentage of ART patients with a suppressed viral load (VL) result (<1000 copies/ml) among those with documented VL test results at the end of quarter 4 is 82.7% in Togo and 77.5% in Burkina Faso. There are many structural challenges with the viral load. Reluctance of providers to request the viral load test because they are discouraged by the long waiting times to obtain results (up to 6 months). The delay in the submission of viral load results to the sites poses the problem of the clinical utility of these results, frequent intrants stock out, etc. During FY21, this issue of viral load will be a priority of the project and consultations with the main stakeholders (PNLS, PSSLS, GF etc.) are planned from the 1st quarter of FY 21 to address this issue.

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• Achievement on core indicators by country Based on a quarterly benchmark of 100% achievement for key indicators and the composite index targets assigned by USAID at the end of quarter 4, the project has overreached the set target for KP_PREV in Togo (172%) and in Burkina Faso (182%). The performance for KP_PREV in both countries includes the contribution of the Key populations investment fund (KPIF) project, the implementation of which started in February 2020 in Togo and in April 2020 in Burkina Faso. The annual target of TX_CURR was also reached in Burkina Faso by the end of quarter 4 with an achievement of 99.7%. For the HTS_TST_POS, the project achieved respectively 98% of the annual target in Togo and 97% in Burkina Faso. The annual target for TX_NEW was achieved at 84% in Togo and 85% in Burkina Faso. Although the results of case finding are generally satisfactory and that the linkage to ART is also satisfactory (greater than 95%), it is in fact noted that the results of TX_NEW are not very satisfactory. This is because the target of TX_NEW was higher than that of HTS_TST_POS when it should have been equal to about 95% case finding. The program was expecting a strong achievement of the annual targets for the key indicators due to the heavy technical assistance and support provided to all sites after the large FY19 to FY20 scale-up. Despite the global COVID-19 pandemic, the heavy technical assistance and support provided in quarters 3 and 4 allowed the project to maintain good achievements during the last two quarters of this fiscal year. This demonstrates the resilience of the project to maintain results.

The Figures 1.a & 1.b and the table 2 provide an overview of the project performance in Q1 to Q4 in Togo and Burkina Faso respectively. Figure 1.a: Number and Percent of FY20 annual targets achieved in Q1 to Q4 (Togo)

7 Figure 1.b: Number and Percent of FY20 annual targets achieved in Q1 to Q4 (Burkina Faso)

Table 2: Cumulative performance for FY20 HTS_TST HTS_TST_POS TX_NEW TX_CURR # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative Togo 112,073 94,070 84% 13,571 13,314 98% 15,265 12,816 84% 41,546 32,808 79% Burkina Faso 44,128 28,083 64% 4,687 4,554 97% 5,279 4,476 85% 25,551 25,483 100% Overall #EAWA 156,201 122,153 78% 18,258 17,868 98% 20,544 17,292 84% 67,097 58,291 87%

• Key strategies and innovations Detailed information on the strategies that were implemented to achieve Q4 and the annual results are provided in section 2. Strategies for reach: - The implementation of provider-initiated testing and counselling (PITC) - The involvement of additional Peer educators (PE) from FSW and MSM population groups in Togo as part of the implementation of the KPIF project; - The assignment of granular specific targets to Peer educators (PE) in their geographic area; - The reinforcement of individual outreach activities (one to one sessions) for key populations; - The organization of EPOA (Enhanced Peer Outreach Approach) campaigns; - The implementation of online prevention and referrals (mainly for MSMs) in Togo. Strategies for HIV testing, linkage and ART initiation - The partnership with surrounding private clinics for the referral of patients suspected of being HIV positive; - The implementation of diversified case finding strategies such as index testing including partner notification services, risk network referral (RNR); - The intensification of targeted community testing to those most at risk;

8 - The implementation of test and start strategy. - The provision of transportation fees to facilitate ART initiation; - The involvement of case managers and peer navigators as HIV testing counselors and first contact in the linkage to ART for HIV positive; - Tailored supervision and coaching to health facilities staff involved in the project; Strategies for ART retention, adherence support and viral load improvement - Differentiated follow-up and home visits by health providers and case managers; - Individual and/or group counseling on treatment adherence by health providers; - Appointment reminders through SMS and phone calls or home visits by case managers; - The use of the e-tracker to track those lost to follow-up ART patients and re-engage them on treatment; - The implementation and scale-up of community ARV refills; - The implementation of the “Come back to care campaign” from August 24 to September 30, 2020 - The transportation of viral load samples to the laboratory.

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Section 2. Description of main results achieved Description of results achieved under the service delivery component

HIV Prevention achievements • KP_PREV A total of 4,844 unique Key populations (3,224 MSMs and 1,620 FSWs) were newly reached with prevention interventions during this fourth quarter in Togo. This achievement includes results performed under the KPIF project. 263% of the quarterly target and 172% of the annual target (cumulative FY20 year to date) of the KP_PREV was achieved in Togo. As shown in Figure 2.a, 87% the KPs reached during this quarter (4,193/4,844) were newly referred and/or tested, 8.7% (n=422) were not eligible for several reasons (recently tested for HIV, have not had sex since their last HIV test, etc.) that put them at low risk for HIV. 4.6% (223/4,844) declined HIV testing and/or referral and 0.1% (n= 6) self-disclosure as known HIV positive.

Figure 2.a: KP_PREV disaggregates by testing services in Q4/FY20 in Togo

Accepted refered Not eligible Declined Known Positive 6000

5000 6 223 4000 4844 422 87% 4193 3000

2000

1000

Number of NumberKPs 0 Reached KPs Test Eligibility

The Figure 2.b shows that the percentage of KPs who accepted referral and/or HIV testing higher among MSMs (90%) than among FSWs (79%).

10 Figure 2.b: KP_PREV disaggregates by testing services and KP type in Q4/FY20 in Togo

In Burkina Faso, a total of 3,377 unique Key populations were newly reached with prevention interventions (627 MSMs and 2,750 FSWs). This represents 336% of the quarterly target and a cumulative annual achievement of 181% FY20 year to date. The quarterly achievement of KP_PREV includes results performed under the KPIF project, the implementation of which started in April 2020 in Burkina Faso. Among KPs, 98% reached (3,312/3,377) were newly referred and/or tested, 52 were not eligible for testing, 11 declined HIV testing and/or referral and 2 self-disclosure as being HIV positive. (Figure 3.a). Figure 3.a: KP_PREV disaggregates by testing services in Q4/FY20 in Burkina Faso

Accepted refered Not eligible Declined Known Positive 4000 11 3500 2 52 3000 2500 3377 98% 3312 2000 1500 1000 500 0 Reached KP Test Eligibility

The percentage of KPs who accepted referral and/or HIV testing is slightly higher among FSWs (98%) than among MSMs (97%) as illustrated in the Figure 3.b.

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Figure 3.b: KP_PREV disaggregates by testing services and KP type in Q3/FY20 in Burkina Faso

• Online prevention and referrals In the context of the COVID-19, the #EAWA team in Togo has intensified the use social media for online HIV prevention and referrals for HIV services uptake. This activity is conducted by EVT towards MSM. Three MSM, knowledgeable in social media were recruited among skilled peer educators to conduct Online prevention and referrals. They were trained in the use of social media for HIV prevention, HIV and STI testing, gender-based violence, stigma and discrimination messaging, and on social media data collection and reporting. They were equipped with laptops, smartphones and internet subscription to carry out services online From July to September 2020, the social media campaign recorded 162 new MSMs and 226 MSMs contacts reached online in Togo. MSMs contacts were reached mainly through Facebook and Gay Romeo (Figure 4).

12 Figure 4: Proportion of MSMs reached by type of social media in FY 20 Q4 in Togo

Among the 226 contacts reached during this quarter, 188 were referred to a service such as HIV testing and STI screening. Some of 188 MSMs were referred for both services. Of those referred to a service, 86% (n= 161) reported to have accessed the service. 144 MSMs were referred for HIV testing and 98% (n= 141) received an HIV test. 107 MSMs were referred for STI screening and 76% (n= 81) reported accessing the referred service.

• Gender based violence prevention and clinical care In quarter four, 1,050 people were sensitized on gender-based violence (GBV) norms and prevention including 723 individuals in Togo and 327 individuals in Burkina Faso. Sensitizations on GBV are conducted by Peer educators (PE) during SBCC outreach activities. 85 cases of GBV have been notified during the quarter in both countries including 78 emotional violence, 5 physical violence and 2 sexual violence. Post-exposure prophylaxis was provided to those who were exposed to sexual violence.

• Key strategies for reach Peer education strategy is based on individual and/or small group discussions in the drop-in centers and on assigned hotspots. During this quarter, additional Peer educators (PE) from KP groups (MSM and FSW) recruited in Togo under the KPIF project have been involved in outreach activities. Specific targets were assigned to

13 each PE within his assigned geographic area. These PE are supervised by peer supervisors who are mostly former skilled and experienced PE. With the support of the KPIF project, EPOA (Enhanced Peer Outreach Approach) campaigns have been organized during this quarter in Togo. Due to the COVID-19 outbreak in March 2020 and the limitations for group activities, KPs outreach activities were focused on individualized counseling sessions in the two countries of implementation. In Togo, the project reinforced the implementation of online prevention and referrals. This activity is conducted only for MSMs and is organized by experienced former MSMs Peer educators.

HIV testing, linkage and ART initiation • HIV testing to ART initiation cascade by country Togo During this quarter, 36,439 individuals (20,438 female and 16,001 male)1 were tested for HIV and received their tests results (HTS_TST) in Togo achieving 130% of the quarterly set target and a cumulative annual achievement of 84% year to date. The HTS_TST_POS among all target populations in Togo during quarter 4 were 3,988 (2,487 female and 1,501 male). This represents 11% case finding and 118% achievement of the quarterly target and 98% of the cumulative annual achievement year to date. Among those diagnosed HIV positive, 96.1% (3,831/3,988) were newly enrolled on ART during the reporting period (Figure 5.a). 100% of the quarterly target and 84% of the annual target2 of TX_NEW were achieved at the end this quarter. The volume of HTS_TST_POS and TX_NEW recorded in Togo increased during this fourth quarter compared to the previous quarter due to the heavy technical support provided to the sub-awardees in the implementation of testing strategies and the test and start approach. Despite the outbreak of the COVID-19 disease in the two countries, the project made some adaptations to be resilient by introducing new activities and/or reinforcing existing activities such as online prevention and referrals, community testing, the organization of weekly sub-awardees coaching and performance review via virtual platforms (Microsoft Teams and Zoom).

1 These data include the KP (MSM and FSW). 2 The target for TX_NEW is greater than the target of HTS_TST_POS. despite the high linkage to ART rate, the performance of TX_NEW is lower than the performance recorded for the HTS_TST_POS.

14 The Figure 5.a illustrates the cascade of HIV testing to ART initiation at the end of quarter 4 in Togo. Figure 5.a: HIV testing to ART initiation cascade in Togo – FY20/Q4

15 Burkina Faso In quarter 4 of the fiscal year 2020, a total of 10,255 individuals (7,203 female and 3,052 male) were offered HTS_TST in Burkina Faso and 11.3% (1,154/10,255) were newly diagnosed HIV positive. Among those diagnosed HIV positive, 97.6% (1,126/1,154) were newly enrolled on ART (Figure 5.b). By the end of quarter 4, the project achieved 93% of the quarterly target for the HTS_TST; 98% for the HTS_TST_POS; and 85% for TX_NEW. As of September 30, 2020, the annual target in Burkina Faso was achieved at 64% for the HTS_TST, 97% for the HTS_TST_POS and 85% for the TX_NEW3. The volume of HTS_TST and TX_NEW recorded in Burkina Faso has increased during this quarter compared to the previous quarter while the volume of the HTS_TST_POS decreased slightly from quarter 3 (1,170) to quarter 4 (1,154). The adaptive measures implemented in Burkina contributed to the resiliency of the project during the context of the COVID-19. These innovative strategies and initiatives include, among others, the reinforcement of the community testing, and the organization of weekly sub-awardees coaching and performance review via virtual platforms (Microsoft Teams and Zoom). In addition, a catch-up plan was developed and implemented during this fourth with strong achievements. The implementation of this plan made it possible to achieve the results achieved at the end of this quarter (Figure 5.b).

3 As explained previously, the target for TX_NEW is greater than the target of HTS_TST_POS. despite the high linkage to ART rate, the performance of TX_NEW is lower than the performance recorded for the HTS_TST_POS.

16 Figure 5.d: HIV testing to ART initiation cascade in Burkina Faso – FY20/Q4

• KPs cascade by country Togo During this quarter, 4,844 individuals KPs (1,620 FSWs and 3,224 MSMs) were newly reached with prevention interventions in Togo. Among the KPs reached, 87% (4,193/4,844) were eligible for HIV testing. 3,976 KPs (1,224 FSWs and 2,752 MSMs) were tested for HIV and 9.9% (394/3,976) were newly diagnosed HIV positive. Among KPs diagnosed HIV positive, 95.9% (378/394) were enrolled on ART in the course of the quarter. As shown on Figure 6.a, the case finding rate was slightly higher among MSMs (11%) than among FSWs (9%). The linkage to ART rate is higher among FSWs (98%) than among MSMs (95%).

17 Figure 6.a: KP cascade in Togo – FY20/Q4 2200

90% 2752 1700 3224 94% 79% 2913

1200 96%

1620 700 9% 1280 1224 98% 11% 95% 200 105 103 289 275

-300

HTS_TST HTS_TST

TX_NEW TX_NEW

KP_PREV KP_PREV

HTSeligible HTSeligible

HTS_TST_POS HTS_TST_POS FSW MSM

Burkina Faso From July to September 2020, 3,377 individuals KPs (2,750 FSWs and 627 MSMs) were newly reached with prevention interventions in Burkina Faso. Among the KPs reached during this quarter in Burkina Faso, 98% (3,312/3,377) were eligible for HIV testing. Among KPs reached during this quarter 2,658 (2,174 FSWs and 484 MSMs) were tested for HIV and 8.6% (228/2,658) were newly diagnosed HIV positive. Among KPs diagnosed HIV positive, 95.2% (217/228) were newly enrolled on ART during the quarter. The linkage to ART rate was higher among MSMs (97%) than among FSWs (95%). The technical assistance provided by #EAWA to health care providers on the motivational interviewing (MI) and on the individualized care and support for the newly diagnosed HIV positive contributed to achieve this high linkage to ART rate. The Figure 6.b provides an overview of the cascade for FSW and MSM during quarter 4.

18 Figure 6.b: KP cascade in Burkina Faso – FY20/Q4

1400 2750 2705 1200 98% 2174 1000 80% 800

600 9% 97% 400 79% 484 95% 627 608 200 8% 97% 189 179 39 38

0

HTS_TST HTS_TST

TX_NEW TX_NEW

KP_PREV KP_PREV

HTSeligible HTSeligible

HTS_TST_POS HTS_TST_POS FSW MSM

• HTS by modality and by country This section highlights the contribution of HTS modalities to the overall HTS and case finding achievements during the quarter.

Togo In Togo, 36,439 individuals received HIV testing service and received their test results during this quarter. The HIV testing yielded 3,988 HIV positive newly diagnosed for a case finding of 11%. As presented in graph 7.a, 40% (n= 14,570) of the HTS achievements during this quarter were performed through Mobile testing; 23% through VCT modality (n= 8,455); 11% through Emergency modality (n= 3,877); and 8% (n= 2,797) through index testing. The overall HTS_TST_POS reported during this quarter is 3,988 among whom 27% (n= 1,057) through Mobile testing; 23% (n= 901) through VCT; 19% through Index testing (n= 740); and 12% through Emergency yard (n= 497). With 8% of contribution to the HTS_TST and 19% to HTS_TST_POS, the index testing modality recorded the highest yield of 26% (740 positives out of 2,797 tested for HIV in Togo during this quarter as presented in graph 7.b.

19 Figure 7.a: Contribution of HTS modalities to testing and case finding in Togo – FY20/Q4

Figure 7.b: HIV testing and case finding by HTS modality in Togo – FY20/Q4

Burkina Faso The graphs 8.a and 8.b depict the distribution of HIV testing and case finding by HTS modalities in Burkina Faso. In Burkina Faso, most of the HTS_TST (89%) and HTS_TST_POS (79%) results were achieved through VCT modality during this quarter as in the previous quarter.

20 The Index testing modality contributed to 5% of the HIV testing and to 13% of the case finding with a yield of 30%.

Figure 8.a: Contribution of HTS modalities to testing and case finding in Burkina Faso – FY20/Q4

Figure 8.b: HIV testing and case finding by HTS modality in Burkina Faso – FY20/Q4

21 • Index testing by country Togo The cascade of index testing in Q4 in Togo (Figure 9.a) shows that, index testing services were offered to 2,102 index cases among whom 1,409 index cases accepted the offer (67% of acceptance). 4,025 contacts were elicited (an elicitation ratio of 2.9) among whom 21 were known HIV positive. 29.9% (1,207/4,025) of the contacts elicited declined the HIV testing. The HIV testing among contacts yielded by 2,057 new HIV negative and 740 new HIV positive with a seropositive rate of 26%. The offer of index testing is low compared to the number of individuals newly diagnosed HIV positive during the quarter. From those newly diagnosed HIV positive, 52.7% (2,102/3,988) were offered index testing service. Although, the offer of index testing increased from 43.2% in Q3 to 52.7% in Q4, it remains low. The index testing is only offered to PLHIV who are willing to accept their HIV status and who can consent to elicit contacts. The project team will reinforce the technical assistance to the sites in order to improve the index testing cascade.

Figure 9.a: Togo Cascade of index testing Q4/FY20

All HIV testing performed through Index testing were conducted with respect for confidentiality, consent, and the rights of clients. The passive referral (69%) was the most method of referral used in Togo during this quarter as shown in Figure 9.b. The proportion of index contacts referred through provider and contract referrals was low (18% and 1% respectively). At the beginning of FY21, additional trainings will be organized and tailored technical assistance on the motivational interviewing (MI) will be planned for health care workers in Togo in order to improve their communication and counseling skills. The aim of this support is to increase the volume of index contacts referrals through provider and contact.

22 Figure 9.b: Index testing by referral methods Q4/FY20 in Togo

Burkina Faso The Figure 10.a illustrates the cascade of index testing in Quarter 4 in Burkina Faso. 465 index cases received index testing services among whom 379 index cases accepted. A total of 569 contacts were elicited (an elicitation ratio of 1.5) among whom 12 known HIV positive. 8.8% (50/569) of the contacts elicited declined the HIV testing. 507 contacts tested for HIV and 157 were newly diagnosed HIV positive which represents a case finding of 31%. The index testing is not yet fully implemented in most of the supported sites in Burkina Faso. The index testing is only offered to PLHIV who are willing to accept their HIV status and who can consent to elicit contacts. 41% of the individuals newly diagnosed HIV positive (465/1,126) were offered index testing service compared to 31% in quarter 3. In quarter 1 of the fiscal year 2021, health workers will be trained and coached in the implementation of the motivational interviewing in order to increase the offer and the acceptance of the index testing services.

23 Figure 10.a: Burkina Faso Cascade of index testing Q4/FY20

As in Togo, the proportion of index contacts referred through provider referral (18%) is lower than the passive referral (72%) in Burkina Faso as shown in Figure 10.b. The technical assistance to health care workers on the motivational interviewing (MI) will be also planned for the improvement of health providers counseling skills. Thus, the volume of index contacts referrals through provider and contact will be increased.

Figure 10.b: Index testing by referral methods Q4/FY20 in Burkina Faso

24 • HTS by sites and by country Togo The highest volume of HIV testing in Togo during this fourth quarter was recorded by Hopital Be (n= 3,548) and EVT (n= 3,102) (Figure 11.a). The maximum HIV positive individuals were diagnosed by EVT (n= 419), CHR Tsévié (n=326) and Hopital Be (n= 301). During this quarter, the project team continued with the weekly performance review calls with each supported site. These calls bring together the project team and the site staff to discuss weekly achievements against targets, the challenges in reaching the targets and the solutions and/or approaches to address the challenges. In quarter 1 of FY21, an annual performance review will be organized with all the implementing sites in order to provide a platform of experience sharing within the project supported sites. The fiscal year 2020 and the lessons learned in FY20 will be discussed during this meeting as well as challenges and priorities of FY21. Figure 11.a: HIV testing and case finding by sites in Togo – FY20/Q4

Burkina Faso In Burkina Faso, Yeleron+ (n= 1,644) and CM Oasis (n= 1,421) recorded the highest number of HIV testing performed during this quarter (Figure 11.b). The maximum number of HIV positive individuals were diagnosed by CM Oasis (n= 179), Yeleron+ (n= 117) and CM Espoir et Vie (n= 107). As in Togo, weekly sites performance review calls initiated in quarter 3 were also organized in Burkina Faso during this quarter. Discussions during these calls are focused on weekly achievements, the challenges in reaching the targets and the solutions and/or approaches to address the challenges.

25 In quarter 1 of FY21, in-country annual performance review with all the implementing sites will be organized in order to provide a platform of experience sharing within the project supported sites in Burkina Faso. Figure 11.b: HIV testing and case finding by sites in Burkina Faso – FY20/Q4

• HIV testing and ART initiation by sub-awardee Togo As in the previous quarters (Q1, Q2 and Q3), CMS Lucia (EVT) diagnosed the highest number of HIV positive (n= 419) and individuals newly enrolled on ART (420) during this quarter. The overall linkage rate to ART is 96.1%. Most of the sites in Togo recorded a linkage rate to ART greater than 90% (Table 2.a). Only 4 facilities over the 25 supported facilities in Togo recorded a linkage to ART rate less than 90%. These sites are: Hopital Notse (75.3%), CHP Vogan (76.9%), CHR Atakpamé (77.0%) and CMS Agoenyive (87.5%). All these sites are publics facilities and are reference hospitals that receive bedridden patients who for clinical reasons are unable to commence ART early, these clients are kept in care while awaiting recovery before enrolling them into ART. Table 2.a: Overview of HIV testing and linkage to ART by sub-awardee in Q4/FY20 in Togo ART linkage No Togo Sub-awardees HTS_TST HTS_TST_POS Yield TX_NEW rate 1 Centre de Santé de Lomé 414 98 23.7% 103 105.1% 2 CHR Lome Commune 532 75 14.1% 73 97.3% 3 CMS Adakpamé 1,567 175 11.2% 179 102.3% 4 Crips-Togo 1,712 98 5.7% 95 96.9% 5 Action Contre Le Sida 2,794 239 8.6% 223 93.3%

26 ART linkage No Togo Sub-awardees HTS_TST HTS_TST_POS Yield TX_NEW rate 6 CMS Amoutivé 628 65 10.4% 67 103.1% 7 Hopital de Be 3,548 301 8.5% 271 90.0% 8 CMS Kodjoviakope 884 62 7.0% 62 100.0% 9 Jade Pour La Vie 1,447 176 12.2% 176 100.0% 10 CHU campus 1,582 140 8.8% 130 92.9% CMS Aide Médical et Charité 11 1,206 149 12.4% 139 93.3% (AMC) 12 CMS Confiance (FAMME) 1,431 161 11.3% 160 99.4% 13 CMS Lucia (EVT) 3,102 419 13.5% 420 100.2% 14 CMS AST Baguida 1,843 196 10.6% 195 99.5% 15 CMS Adidogomé 924 139 15.0% 129 92.8% 16 CMS Agoenyive 788 176 22.3% 154 87.5% 17 CMS Espoir Vie Vue (E2V) 831 90 10.8% 91 101.1% Centre Hospitalier Préfectoral 18 1,545 203 13.1% 223 109.9% Aného 19 CHP vogan 1,352 134 9.9% 103 76.9% CMS Soeurs de La Providence 20 1,783 277 15.5% 271 97.8% de Kouve 21 CHR Tsévié 2,037 326 16.0% 321 98.5% 22 Hopital de Notse 904 89 9.8% 67 75.3% 23 CHP Kpalime 1,106 82 7.4% 75 91.5% 24 CHR Atakpame 928 61 6.6% 47 77.0% 25 Polyclinique Atapkame 1,551 57 3.7% 57 100.0% Togo Overall 36,439 3,988 10.9% 3,831 96.1%

Burkina Faso In Burkina Faso, CM Oasis diagnosed the highest number of HIV positive and enrolled also the highest number of patients on ART (179 and 175 respectively) during this quarter. By the end of quarter 4, the overall linkage to ART rate in Burkina Faso was 97.6%. Some sites in Burkina Faso such as CHU Bogodogo, Yeleron+, and CM Samandin recorded a linkage to ART rate less than 90% (Table 2.b). The main reason given to explain this low rate of linkage to ART is the fact that some people who tested positive are passing through the site and prefer to return to their city of residence before starting treatment. The project team will provide tailored technical assistance to the facilities with a low linkage to ART rate in the implementation of the test and start strategy. Table 2.b: Overview of HIV testing and linkage to ART by sub-awardee in Q4/FY20 in Burkina Faso

Burkina Faso Sub- ART linkage No HTS_TST HTS_TST_POS Yield TX_NEW awardees rate 1 CM Oasis 1,411 179 12.7% 175 97.8% 2 CM Samandin 584 80 13.7% 69 86.3% 3 Yerelon+ 1,643 117 7.1% 97 82.9% 4 CHU Bogodogo 726 98 13.5% 25 25.5%

27 Burkina Faso Sub- ART linkage No HTS_TST HTS_TST_POS Yield TX_NEW awardees rate 5 CHU/CDG 209 18 8.6% 17 94.4% 6 CM Alavi 456 51 11.2% 51 100.0% 7 CM Vie Positive 545 35 6.4% 53 151.4% 8 CMA Pissy 476 89 18.7% 93 104.5% 9 CMA Kossodo 278 53 19.1% 61 115.1% 10 CMA Paul VI 378 44 11.6% 56 127.3% 11 DS Koudougou 415 82 19.8% 87 106.1% 12 CM Réo 504 22 4.4% 61 277.3% 13 CM Espoir et Vie 916 107 11.7% 111 103.7% 14 HDJ 372 89 23.9% 85 95.5% 15 CM REVS+ 412 39 9.5% 36 92.3% 16 CM Yérélon 320 25 7.8% 24 96.0% 17 CMA Houndé 610 26 4.3% 25 96.2% Burkina Faso Overall 10,255 1,154 11.3% 1,126 97.6%

• Key strategies for HIV testing, linkage and ART initiation During this quarter, supportive technical coaching was provided to health care workers to ensure an effective implementation of case finding strategies and also the implementation the test and start strategy at site level. The supportive coaching session provided to the sites contributed to the achievements of the HIV case finding and the linkage rate to ART obtained during this quarter despite of the advent the COVID- 19 disease. With the outbreak of the COVID-19 in the two countries, recovery plans were implemented in both countries with a focus on community testing. Enhanced peer outreach approach (EPOA) campaigns are also organized in both Togo and Burkina Faso. These campaigns target especially KPs. To cope with the restrictions of traveling and triage at the entrance of facilities, weekly virtual coaching sessions and performance review were organized via Microsoft Teams and Zoom. The project also put an emphasis on the involvement of case managers as HIV counselors in the implementation of the test and start strategy. As HIV counselors, case managers are the first contact of HIV testing clients. They are responsible of the counseling before testing, the post-counseling and the announcement of the test results. Anyone who has been diagnosed HIV positive is directly linked to a case manager who ensures his linkage to care and to ART.

Retention on ART and viral load suppression • Retention on ART At the end of this quarter, the project achieved 79% of the TX_CURR annual target in Togo and 99.7% in Burkina Faso.

28 In August 2020, the project recorded a noticeable number of Lost to follow-up (LTFU) ART patients in both Togo and Burkina Faso affecting the trend of the TX_CURR. In order to address this retention issue, a “Come back to care” campaign was organized in both countries. This campaign has enabled the project to bring back to treatment several LTFU patients and improve the TX_CURR at the end of Q4. Several measures are taken to limit the number of lost to follow-up from the 1st quarter of FY21. Among other measures, systematically record the contacts of PLHIV on treatment in order to contact them to send messages to remind them of their appointment for ARTs refill, contact the defaulters before they find themselves lost to follow-up and make an active search for LTFU.

Togo As stated above, the project recorded a noticeable number of LTFU ART patients affecting negatively the trend of the TX_CURR. The TX_CURR decreased from 29,181 at the end of Q3 to 28,567 in August 2020 (Figure 12.a). Figure 12.a: Trend of the TX_CURR from September 2019 to September 2020 in Togo

A cumulative number of 9,299 LTFU was recorded in the e-tracker since the beginning of the Game changer in Togo. This represented a proportion of LTFU of 24.6% as of August 24, 2020. With the “Come back to care campaign”, 34% of the total LTFU were reengaged on treatment by September 30, 2020 (Figure 12.b). Thanks to this campaign, 19% of the total number of LTFU have been updated in the e-tracker, 16% were documented transfer-out, 8% with no tracing information, and 7% documented deceased. By September 30, 2020 there were 1,117 remaining LTFU to be found at site level corresponding to a proportion of LTFU of 3.3% at the end of quarter 4.

29 Figure 12.b: Come back to care campaign achievements in Togo

At the end of quarter 3, a total of 29,124 PLHIV had been cumulatively enrolled on ART at projects’ sub-awardees facilities. From July 1 to September 30, 2020, a total of 3,831 PLHIV (adults and children) were newly enrolled on ART in Togo. As of September 30, 2020, the project’s TX_CURR is 32,808 PLHIV achieving 79% of the annual target as approved in the revised project description. This set target was calculated using an initial TX_CURR of 29,265 provided by the NACP/Togo. This value provided by the NACP was overestimated and was calculated using a definition of LTFU for ≥90 days. Using the PEPFAR definition of LTFU for ≥28 days, the initial TX_CURR generated by the e-tracker was 22,016; which is an overestimation of 7,249. Based on this value, the estimated TX_CURR target should be 34,297 (Figure 12.a) and the annual achievement of the TX_CURR should be 95.7%. The figure 12.c provides the overview of the trend in TX_NET_NEW from Q1 to Q4 of this fiscal year in Togo.

30 Figure 12.c: Trends in TX_NET_NEW from Q1 to Q4/FY20 in Togo

The Come back to care campaign yielded also a good retention rate. Based on the retention proxy calculation used by PEPFAR, 76% (19 sites over 25) sites recorded a retention greater than or equal to 95% as shown in Figure 12.d. Figure 12.d: Retention rate by facility in Q4/FY20 in Togo

Burkina Faso As in Togo, the TX_CURR in Burkina Faso decreased significantly from 22,942 in June 2020 to 17,231 in August 2020 (Figure 13.a).

31 Figure 13.a: Trend of the TX_CURR from September 2019 to September 2020 in Burkina Faso

A cumulative number of 10,362 LTFU was recorded in the e-tracker since the beginning of the Game changer in Burkina Faso. The proportion of LTFU was 37.6% as of August 24, 2020. The Figure 13.b depicts that with the “Come back to care campaign”, 52% (n= 5,389) of the total LTFU with no ARV refills information have been updated in the e-tracker, 14% (n= 1,451) were successfully reengaged on treatment, 10% (n= 1,036) were transfer-out, 2% (n= 207) were died and 14% (n= 1,450) were remaining LTFU to be traced at site level by September 30, 2020. The remaining 1,450 LTFU correspond to a proportion of LFTU of 5.4% as of September 30, 2020.

32 Figure 13.b: Come back to care campaign achievements in Burkina Faso

By June 30, 2020, the TX_CURR of Burkina Faso was 22,018 PLHIV and 25,483 at the end of quarter 4 achieving 99.7% of the annual target. The come back to care campaign contributed in achieving this performance. A total of 1,126 individuals were newly enrolled on ART during this quarter with a TX_NET_NEW of 3,465. The figure 13.c provides an overview of the trend in TX_NET_NEW from Q1 to Q4 of this fiscal year in Burkina Faso.

33 Figure 13.c: Trends in TX_NET_NEW from Q1 to Q4/FY20 in Burkina Faso

With the heavy technical support provided during the Come back to care campaign, 15 facilities over 17 in Burkina Faso recorded a good retention rate. (Figure 13.d). Figure 13.d: Retention rate by facility in Q4/FY20 in Burkina Faso

• Viral load suppression Togo The viral load data have been extracted from national electronic database of the laboratory information system in order to minimize viral load data collection errors. Only the sites supported by the project data have been extracted.

34 From October 2019 to September 2020, the total number of ART patients with a viral load result documented in the laboratory records was 13,531 among whom 83% (n= 11,186) had a suppressed viral load result (<1,000 copies/ml). 52% of eligible ART patients did a test of viral load with a documented result (Figure 14.a). There have been several stock-out episodes of viral load tests reagents which have caused delays in testing and delivery of test results. These delays in the submission of results discouraged the providers who no longer saw the interest in requesting tests whose results would sometimes deliver after 6 months and which would no longer have clinical utility. That consequently impacted the offer and demand for viral load tests and ultimately the coverage of viral load. As mentioned above one of the priorities of the project will be to improve VL systems in FY 21. The TX_PVLS recorded in Togo at the end of this quarter (83%) is less than the target of 85% assigned by the donor. In FY21, the project team will reinforce the supportive assistance to the facilities in providing adherence support to the unsuppressed patients. Figure 14.a: Togo Cascade of viral load testing and suppression Q4/FY20

Burkina Faso The viral load data was also extracted from the national electronic laboratory database for the sites supported by the project in Burkina Faso with a completeness of 47% of the projects’ sites. Based on the viral load data received, there was viral load documented result for 2,015 ART patients from October 2019 to September 2020. Only 9% of eligible ART patients did a test of viral load with a documented result in Burkina Faso (Figure 14.b). The Percentage of ART patients with a suppressed viral load result (<1000 copies/ml) in Burkina Faso by the end of quarter 3 was 78% (n= 1,094). There has been likely adherence issue with patient not showing viral load suppression. The project team will provide supportive assistance to the facilities in providing adherence support to the unsuppressed patients.

35 As in Togo, the big issue is related to the stock-out of viral load tests and reagents that impacts also the demand and the coverage of viral load. This issue is not under the control of the project team.

Figure 14.b: Burkina Faso Cascade of viral load testing and suppression Q4/FY20

• Key strategies for ART retention and adherence support The core activity implemented during this quarter in order to improve retention on ART in both Togo and Burkina Faso was the “Come back to care” campaign. From August 24 to September 30, a total of 3,158 lost to follow-up in Togo and 1,465 in Burkina Faso have successfully reengaged on treatment. Strategies deployed for retention and adherence on ART include: (1) differentiated follow-up and home visits conducted by case managers; (2) individual and/or group counseling on treatment adherence organized by health providers; (3) appointment reminders through SMS and phone calls or home visits by case managers; and (4) the introduction of the community and home based ARV refill through case managers during the outbreak of the COVID-19. quartering FY21, the project will continue to provide support to facilities by extracting the lists of ART patients expected for ARV refill for reminders and the list of defaulters for recalls. The #EAWA project will recruit and involve additional case managers and peer navigators in order to improve the case management.

Full cascade of prevention, care and treatment The full cascade of prevention, care and treatment is therefore presented as follows in each of the two countries:

36 Figure 15.a: Togo Cascade of prevention, care and treatment in Q4/FY20

Figure 15.b: Burkina Faso Cascade of prevention, care and treatment in Q4/FY20

37 Description of results achieved under the KPIF project

KPIF achievements in Togo The Key populations investment fund (KPIF) project started field activities in Togo in February 2020 with four subawards, two with community clinics: FAMME and EVT; and two KP-led partners: AFAZ and Reseau Cupidon. During this quarter, a total of 2,564 individuals KPs were newly reached in Togo via the KPIF project including 684 FSW and 1,880 MSM. 96% (2,292/2,399) of those eligible (newly tested and/or referred plus declined for HTS) were tested for HIV; 12% were diagnosed HIV positive, and all were linked to ART. Considering annual targets, KPIF achieved by the end of Q4/ FY20 in Togo, 139% of the target of KP_PREV, 126% for HTS_TST, 107% for HTS_TST_POS and 119% for TX_NEW (Figure 16). Figure 16: Cumulative Cascade for Key Populations of KPIF Togo - FY20 Year to Date

Performances across the HIV cascade among MSM and FSW by KPIF sub-awardees in Togo are as follow in Table 3:

38 Table 3: Cumulative performance by IPs for FY20 up to September 2020 Key Populations of KPIF Togo Indicators KP_PREV HTS_TST HTS_TST_POS TX_NEW KPIF TOGO # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative FAMME 1,000 1,539 154% 871 1,076 124% 113 120 106% 102 120 118% AFAZ 516 659 128% 450 557 124% 58 64 110% 53 64 121% TOTAL FSW* 1,469 2,198 150% 1,280 1,633 128% 166 184 111% 150 184 123% EVT 2,000 2,833 142% 1,648 2,249 136% 264 270 102% 237 270 114% CUPIDON 1,281 1,397 109% 1,055 1,030 98% 169 172 102% 152 172 113% TOTAL MSM/TG* 3,164 4,230 134% 2,607 3,279 126% 417 442 106% 375 442 118% TOTAL KP* 4,633 6,428 139% 3,887 4,912 126% 583 626 107% 525 626 119%

*USAID Target

Based on the annual benchmark of 100% achievement for all key PEPFAR indicators, KPIF Togo exceeded targets across the HIV cascade among FSW and MSM by the end of Q4. This is the case for FAMME, AFAZ and EVT. However, CUPIDON exceeded the targets for KP_PREV, HTS_TST_POS and TX_NEW; but practically met the target of HTS_TST with 98%. The FSW program had strong cumulative performance at the end of Q4, with an achievement level of 150%, 128%, 111%, and 123% for KP_PREV, HTS_TST, HTS_TST_POS, and TX_NEW, respectively. The MSM program had a strong overall cascade with 13% case finding and 100% ART initiation rates. Overall, when combining both programs, the achievements were 139%, 126%, 107%, and 119% for KP_PREV, HTS_TST, HTS_TST_POS, and TX_NEW, respectively.

KPIF achievements in Burkina Faso The KPIF project started field activities in Burkina Faso in April 2020 with three subawards: Yeleron+, Espoir et Vie and AAB. During this quarter, a total of 3,879 individuals KPs were newly reached in Burkina Faso via the KPIF project including 3,348 FSW and 531 MSM. 79% (2,846/3,621) of those eligible (newly tested and/or referred plus declined for HTS) were tested for HIV. 191 KPs were diagnosed HIV positive, and 198 including 8 previously diagnosed HIV positive were linked to ART. Year to date, KPIF Burkina Faso has reached 173% of KP_PREV annual target, 152% of HTS_TST annual target, 110% of HTS_TST_POS annual target and 123% of TX_NEW annual target (Figure 17).

39 Figure 17: Cumulative Cascade for Key Populations of KPIF Burkina Faso for - FY20 Year to Date

Performances across the HIV cascade among MSM and FSW by sub-awardees are as follow in Table 4:

Table 4: Cumulative performance by IPs for FY20 up to September 2020 Key Populations of KPIF Burkina Faso Indicators KP_PREV HTS_TST HTS_TST_POS TX_NEW KPIF Burkina Faso # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative YERELON Plus 1,195 2,793 234% 1,048 1,988 190% 118 134 114% 106 134 126% AAS 305 552 181% 268 256 96% 27 24 89% 24 24 100% EV (FSW) 1,088 1,243 114% 954 1,243 130% 105 116 110% 94 116 123% TOTAL FSW 2,588 4,588 177% 2,270 3,487 154% 250 274 110% 224 274 122% AAB 473 696 147% 422 606 144% 42 48 114% NA NA NA EV (MSM) NA NA NA NA NA NA NA NA NA 38 48 126% TOTAL MSM 473 696 147% 422 606 144% 42 48 114% 38 48 126% TOTAL KP 3,061 5,284 173% 2,692 4,093 152% 292 322 110% 262 322 123%

Based on the annual benchmark of 100% achievement for all key PEPFAR indicators, KPIF Burkina Faso exceeded targets across the HIV cascade among FSW and MSM by the end of Q4. At the end of Q4, the FSW program had strong cumulative performance for KP_PREV, HTS_TST with an achievement level of 177% and 154% respectively. Alternatively, the MSM program had strong cumulative performance for HTS_TST_POS, and TX_NEW with an achievement level of 114% and

40 126% respectively. The both programs had a strong ART initiation rates of 100%. Overall, when combining both programs, the achievements were 173%, 152%, 110%, and 123% for KP_PREV, HTS_TST, HTS_TST_POS, and TX_NEW, respectively

Implementation of the Environmental Monitoring and Mitigation Plan (EMMP)

During this quarter, 8,221 key populations (3,377 in Burkina Faso and 4,844 in Togo) have been reached with HIV prevention interventions designated for the target population. All these KPs have been sensitized on the proper management of waste condoms and lubricants.

Protecting Life in Global Health Assistance (PLGHA)

FHI360 has adhered to the “Protecting Life in Global Health Assistance” policy adopted by the US government as it applies to non-governmental organizations (NGOs) that receive U.S. funding for global health assistance. The policy requires foreign NGOs to agree, as a condition of receiving global health assistance that they will not perform or actively promote abortion as a method of family planning. This policy encompasses all global health programs, including, among other programs, HIV/Aids. To that effect, #EAWA team continuously ensured that all its sub-awardees comply with PLGHA policy. At the beginning of the program, all sub-awardees have filled a due diligence checklist on PLGHA and adhered to the PLGHA policy by signing an abortion prohibition clause as part of their grant agreement.

41 Section 3. Discussion of challenges to implementation The table 5 provides an overview of key challenges to project’s implementation and proposed solutions. Table 5: Key challenges to project’s implementation Challenges/difficulties Solutions Prevention Stock-out of STI kits and HIV test (“First Discussion has been engaged with national response”) stakeholders (PNLS, PSSLS, FTO and PSM) in order to address this challenge Case finding - Several stock-out for HIV test (“First - Discussion has been engaged with the PNLS in response”) in Togo Togo and PSSLS in Burkina Faso in order to address this challenge as the purchase of

commodities is not allowed on this project.

- Continuous discussions have been engaged with FTO in Togo and PSM in Burkina Faso regarding RTK stock

- Training of health care providers - The offer of index testing is low - Reinforce the implementation of Index

Testing by regular coaching and supportive technical assistance Treatment and - Stock-out of ARV - Continuous discussions have been engaged retention on with FTO in Togo and PSM in Burkina Faso

regarding ARV stock-out ART

- Only few ART patients are receiving MMD - Use the e-tracker to support sites in the 3-5 months and none on MMD 6+ months identification of the eligible MMD patients. in Togo. - Advocate with the NACP for the implementation of MMD 6

Viral load - Stock-out of viral load reagents - Advocate with the NACP and other relevant testing - There are delays in the provision of viral stakeholders for viral load reagents supply load results in both countries - Advocate with the NACP in order to reduce delays in providing viral load results

- Recruitment of data entry agents to speed up - Low coverage and poor access to viral load data entry in viral load laboratories. - Involvement of peer navigators in the viral load management in order to increase the demand

42 Monitoring of key assumptions ▪ Political stability: Since the end of 2017, Togo has been witnessing political demonstrations that sometimes disrupt public order. From January to February 2020, the country organized presidential election. Political demonstrations during this election period disrupted the smooth running of project activities in the country. Burkina Faso is facing attacks by jihadist groups that affect the security situation in several parts of the country. These attacks resulted in the displacement of people and restrictions in travelling to some projects sites in order to provide technical support.

▪ Commitment of the various countries’ ministries of health, their National AIDS Control Committees/Programs to support program implementation: During this quarter, the Ministry of Health (through the PNLS and PSSLS) and the CNLS in both Burkina Faso and Togo have demonstrated their commitment to project activities by actively organizing monthly meetings of the steering committee of the project in both countries. In Togo, the PNLS is acting as a main technical partner of the project with responsibilities in national supervision, quality control, training, and lab strengthening activities .The monthly steering committee meetings were held regularly under the heading of CNLS with the participation of all key stakeholders to discuss the overall program implementation and address bottlenecks. In Burkina, the framework of collaboration with the PSSLS was finalized, and a consensus was reached on the operationalization of the program steering committee with USAID and the SP/CNLS.

▪ COVID-19 pandemic: Since March 2020, the COVID-19 pandemic is impacting the implementation of the project activities. In both countries (Burkina Faso and Togo), a triage system has been introduced at the entrance of health facilities and limits access to clients. This measure is affecting HIV testing occurring in facilities such as VCT, index testing and other PITC. In some sites, health care workers assigned to the project has been redeployed to COVID-19 patient management sites. This affects the provision of HIV screening services, as well as PLHIV care and treatment services. A few of #EAWA partner tertiary hospitals are designated as referral points for the management of suspected and confirmed COVID-19 cases. Other sites were designated as treatment and care centers for COVID-19 patients. This has created disruption in the continuum of services. This has also meant that patient traffic flow within and outside the hospital, including workforce and other resources, were drastically disrupted. The lack of personal protection equipment has impaired the ability of health workers to provide HIV services in clinical settings, but also discouraged community workers in engaging in community activities.

A contingency plan has been developed to mitigate the COVID-19 impact on the continuation of operations.

The project has demonstrated resilience towards the pandemic as suggested by the adverse impact of performance, in both Togo and Burkina Faso, that has been largely mitigated through implementation of adaptative measures and innovative strategies discussed in this

43 report. The close collaboration with national stakeholders since the beginning of the pandemic to tackle key challenges has also been pivotal in laying the ground for a resilient ecosystem despite the constraining factors brought about by the COVID-19 situation.

Section 4. Activities planned for next quarter Major activities planned for the next quarter are described as follows: - Finalization of sub-awards for FY21 in both country - Continued technical supervision and coaching on technical approaches of case finding, documentation of index testing, retention, and viral load testing; - Continued collaboration with organizations and authorities along the supply chain to address bottlenecks; - Organization of monthly steering committee meetings in both countries; - Organization of coordinating meeting with project supported health facilities in Togo and in Burkina Faso; - Organization of the annual review of FY20 achievements with all the supported sites in each implementing country; - Implementation of the HIV self-testing in Togo; - Advocacy with the NACP for the introduction of HIV self-testing in Burkina Faso.

44 Section 5. Financial brief 1-Obligated amount

2- Expenditures for Q4 FY20 and Cumulative Expenditures

3- Subgrantees Disbursements (Q4 FY2020) and cumulative

4- Next Quarter Projections (Q1 FY2021)

5- Next Quarter Subgrantees Planned Disbursement (Q1 FY2021)

45 Section 6. Summary of FY20 annual achievements Annual achievements on core indicators Efforts in this fiscal year were concentrated on HIV testing, case finding and ART initiation targets in both countries. These efforts have yielded good results. Both countries efforts culminated in reaching the annual set target of most of the core indicators except HTS_TST and TX_NEW. (Table 6).

In Togo, a total of 12,741 keys populations (7,390 MSMs and 5,351 FSWs) were reached with prevention interventions in the course of this fiscal year. 172.8% (12,741/7,373) of the annual set target for KP_PREV was achieved. Efforts in providing HIV testing services resulted in achieving 84% (94,070/112,073) of the annual HST_TST target. At the same time, the project achieved 98% (13,314/13,571) of the annual target for HIV case finding (HTS_TST_POS). This is attributable to the implementation of new case finding approaches such as index testing, EPOA, the mobile testing and the differentiated provider-initiated testing and counseling. The HIV yield for all target populations in Togo during FY20 is 14.2%. 12,816 HIV positive individuals were newly enrolled on ART during this fiscal year which represents a linkage rate to ART of 96.3% and an annual achievement of 84%. The total number of adults and children receiving ART in project supported facilities in Togo (TX_CURR) at the end of FY20 was 32,808 and the percentage of ART patients with a suppressed viral load (<1000 copies/ml) was 83%.

In Burkina Faso, a total number of 7,312 individuals’ key populations (including 1,281 MSMs and 6,031 FSWs) were with prevention interventions from October 2019 to September 2020. This is an achievement of 182% of the annual set target for KP_PREV. 64% of the HTS_TST target was achieved (28,083/44,128) and 97% of the HTS_TST_POS target (4,554/4,687). The overall HIV case finding rate for Burkina Faso in FY20 is 16.2%. The total number of HIV positive newly enrolled on ART during FY20 is 4,476 which represents 85% of the annual target and a linkage to ART rate of 98.3%. At the end of this fiscal year, the TX_CURR in Burkina Faso was 25,483 achieving 99.7% of the annual target. The percentage of ART patients with a suppressed viral load (<1000 copies/ml) was 78%.

Table 6: Overview of FY20 annual achievement on core indicators by country Togo Burkina Faso Overall #EAWA countries % of % of FY20 % of FY20 Key Target FY20 FY20 FY20 FY20 FY20 FY20 FY20 targets targets indicators population Target Achievement targets Target Achievement Target Achievement achieved achieved achieved MSM 5,274 7,390 140.1% 788 1,281 162.6% 6,062 8,671 143.0%

KP_PREV FSW 2,099 5,351 254.9% 3,235 6,031 186.4% 5,334 11,382 213.4% KP overall 7,373 12,741 172.8% 4,023 7,312 181.8% 11,396 20,053 176.0%

MSM 4,344 5,379 123.8% 703 1,154 164.2% 5,047 6,533 129.4% FSW 1,829 3,726 203.7% 2,837 5,785 203.9% 4,666 9,511 203.8% HTS_TST PP & 105,900 84,965 80.2% 40,588 21,144 52.1% 146,488 106,109 72.4% Others Overall 112,073 94,070 83.9% 44,128 28,083 63.6% 156,201 122,153 78.2%

HTS_TST_POS MSM 695 647 93.1% 70 96 137.1% 765 743 97.1%

46 Togo Burkina Faso Overall #EAWA countries % of % of FY20 % of FY20 Key Target FY20 FY20 FY20 FY20 FY20 FY20 FY20 targets targets indicators population Target Achievement targets Target Achievement Target Achievement achieved achieved achieved FSW 238 374 157.1% 312 585 187.5% 550 959 174.4% PP & 12,638 12,293 97.3% 4,305 3,873 90.0% 16,943 16,166 95.4% Others Overall 13,571 13,314 98.1% 4,687 4,554 97.2% 18,258 17,868 97.9%

MSM 626 602 97.2% 63 85 134.9% 689 687 99.7%

FSW 214 368 172.0% 281 509 181.1% 495 877 177.2% TX_NEW PP & 14,425 11,846 82.1% 4,935 3,882 78.7% 19,360 15,728 81.2% Others Overall 15,265 12,816 84.0% 5,279 4,476 84.8% 20,544 17,292 84.2%

MSM 1,034 756 73.1% 235 177 75.3% 1,269 933 73.5%

FSW 671 601 89.6% 704 956 135.8% 1,375 1,557 113.2% TX_CURR PP & 39,841 31,451 78.9% 24,612 24,350 98.9% 64,453 55,801 86.6% Others Overall 41,546 32,808 79.0% 25,551 25,483 99.7% 67,097 58,291 86.9%

TX_PVLS Overall 85% 83% 85% 78% 85% 82%

Trend of key indicators over the four quarters of FY20 In Togo, a significant progress has been observed for the core indicators in Q4 compared to Q1, Q2 and Q3 (Figure 18). The linkage rate to ART remained higher in Togo during this fiscal year (≥95%). The seropositivity rate decreased from 18% in Q1 to 16% in Q2, 15% in Q3 and 11% in Q4. The TX_CURR has increased constantly from a quarter to another during this fiscal year demonstrating efforts made in maintaining on treatment old ART patients and those newly enrolled on ART. Figure 18: Trend of performance for key indicators during FY20 in Togo

47 In Burkina Faso, there has been a constant increase in HTS_TST and TX_CURR results during this fiscal year. The graph 19 below presents on overview of the trend of key indicators in Burkina Faso during this fiscal year. The decrease observed in the linkage rate to ART in quarter 3 (92%) has been improved to 98% in Q4. Figure 19: Trend of performance for key indicators during FY20 in Burkina Faso

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