USAID Community HIV Prevention

Project

Year 5 – FY20 Quarter One Report 01 October 2019 to 31 December 2019

Contract/Agreement Number: AID-611-A-16-00001 Activity start and end date: November 23, 2015 – November 22, 2020 Total award amount: $59,999,859

Prepared for: Arlene Phiri, Agreement Officer’s Representative, USAID, Embassy Building, Kabulonga Road, Lusaka, Zambia Submitted by: Charles Ossey, ICD/Chief of Party, Pact Zambia, Plot 35186, Block A, Mass Media, Alick Nkhata Road, Lusaka, Zambia; telephone: +260 211 254 089/91; email: [email protected]

Table of Contents Abbreviations and Acronyms ...... 3 1. Section 1: Program Background ...... 4 ▪ Executive Summary ...... 4 ▪ Strategic Objective 1: Key determinants of risky behavior reduced among priority populations ...... 4 ▪ Strategic Objective 2: Increase in completed referrals from community programs to high impact services ...... 4 ▪ Strategic Objective 3: Actions adopted by communities to reduce young women’s vulnerability to HIV, unintended pregnancy and Sexual and Gender-Based Violence ...... 5 ▪ Strategic Objective 4: Strengthened capacity of local stakeholders to plan, monitor, evaluate and ensure the quality of HIV preventions ...... 5 2. Section 2: Major Accomplishments towards Program Objectives ...... 5 2.1 Strategic Objective 1: Key determinants of risky behavior reduced among priority populations ...... 5 2.2 Strategic Objective 2: Increase in completed referrals from community programs to high impact services ...... 8 2.3 Strategic Objective 3: Actions adopted by communities to reduce young women’s vulnerability to HIV, unwanted pregnancy and SGBV ...... 13 2.4 Strategic Objective 4: Strengthened capacity of local stakeholders to plan, monitor, evaluate and ensure the quality of prevention interventions ...... 17 3. Section 3: Cross-Cutting Activities and Updates ...... 19 4. Section 4: Challenges and Opportunities for Improvement ...... 21 5. Section 5: Highlights of FY20 Quarter 2 Activities ...... 22 SUCCESS STORY ...... 23 SUCCESS STORY ...... 24 Summary Indicator Table ...... 25

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ABBREVIATIONS AND ACRONYMS

AGYW Adolescent Girls and Young Women ART Anti-Retroviral Therapy CHEP Copperbelt Health Education Program CMMB Catholic Medical Mission Board CSE Comprehensive Sexuality Education DHAC District HIV and AIDS Committee DQA Data Quality Assessment DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe ECR Expanded Church Response EYL Enterprise Your Life FY Fiscal Year HIV Human Immunodeficiency Virus HTS HIV Testing Services ISP Institutional Strengthening Plan MoGE Ministry of General Education MoH Ministry of Health NAC National AIDS Council NGO Non-Governmental Organization OPI Organizational Performance Index OVC Orphans and Vulnerable Children PEPFAR U.S. President’s Emergency Plan for AIDS Relief PLHIV People Living with HIV PrEP Pre-Exposure Prophylaxis PSGBV Post Sexual and Gender-Based Violence Care RDQA Routine Data Quality Assessment SBCC Social and Behavior Change Communication SBPI School-Based Prevention Intervention SGBV Sexual and Gender-Based Violence SIA Sport in Action STI Sexually Transmitted Infection UNAIDS United Nations Program on HIV/AIDS USAID United States Agency for International Development VCT Voluntary Counselling and Testing YWCA Young Women’s Christian Association ZCCP Zambia Center for Communication Programs Z-CHPP Zambia Community HIV Prevention Project ZHECT Zambia Health Education and Communication Trust

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1. Section 1: Program Background

▪ Executive Summary Pact hereby submits the FY20 quarter one report for the United States Agency for International Development Zambia Community HIV Prevention Project (USAID Z-CHPP). Pact implements the project with Plan International, Sport in Action (SIA), Copperbelt Health Education Project (CHEP), Zambia Health Education Communication Trust (ZHECT), Zambia Center for Communications Program (ZCCP), Catholic Medical Mission Board (CMMB) and Young Christian Women Association (YWCA). The project’s goal is to reduce new HIV infections in Zambia. It focuses on People Living with HIV (PLHIV); Adolescent Girls and Young Women (AGYW); Mobile and Migrant Populations (MMP), Non-Injecting Drug Users (NIDUs) and Discordant Couples (DCs).

The report is for the period of 01 October 2019 to 31 December 2019. It covers progress towards project objectives, achievements, challenges and opportunities for improvement. It summarizes human resource; grants and finance management. It ends with an outline of activities for quarter 2 of FY20; two success stories and an indicator summary table reflecting FY20 quarter one progress towards targets. The project successfully mobilized priority population individuals for high-impact HIV services. Behavioral, biological and structural approaches were employed to mitigate determinants of risky behavior; facilitate uptake of HIV services; reduce AGYW vulnerability to HIV and increase stakeholders’ capacity for HIV response. Project implementation was on track with progress made towards meeting targets.

The key achievements for the period were: ▪ Strategic Objective 1: Key determinants of risky behavior reduced among priority populations USAID Z-CHPP used pre-recorded radio programs, community dialogues and popular theatre to create demand and mobilize 156,700 priority population clients for high-impact HIV services. The clients completed a standardized HIV prevention intervention package which is based on evidence and meets required minimum standards. 1,870,026 condoms were distributed out of which 168,631 were accessed by AGYW in Safe Spaces including DREAMS Centers.

▪ Strategic Objective 2: Increase in completed referrals from community programs to high impact services The project identified 1,074 HIV positive clients and referred them for ART; out of which 1,050 initiated treatment. This represented a linkage rate of 98%. With and without DREAMS, the

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positivity rate was, respectively, 17% and 31%. The project distributed 9,976 HIV Self-Test Kits (HIVST) to priority population clients. ▪ Strategic Objective 3: Actions adopted by communities to reduce young women’s vulnerability to HIV, unintended pregnancy and Sexual and Gender-Based Violence 57,429 AGYW were enrolled into DREAMS Safe Spaces where they accessed a gamut of services including HIV prevention; family planning; referrals for ART, STI screening and Post Gender- Based Violence Care; education and economic strengthening. Through DREAMS, 77 AGYW were found positive and referred for ART out of which 75, representing 97%, initiated treatment. 49,519 AGYW graduated from Safe Spaces; accounting for 86% of those enrolled. 6,215 priority population individuals were trained in savings out of which 5,237 were AGYW. 204 savings groups were formed out of which 154 were specific to DREAMS. ▪ Strategic Objective 4: Strengthened capacity of local stakeholders to plan, monitor, evaluate and ensure the quality of HIV preventions Pact facilitated organizational and technical development exercises for sub-partners. It trained, mentored, backstopped and provided financial support to sub-partners and stakeholders to enable them to plan, implement and monitor the HIV response. The result was coordinated and effective response to HIV in 14 districts where the project is implemented. ▪ Key Challenges The key challenges faced in the quarter were stockouts of condoms and HIVST kits that slowed down HIV prevention activities; delayed data entry and reporting due to DHIS2 system challenges and erratic power supply; delayed roll-out of SMARTCARE Lite and non-implementation of the parenting program. Pact brought these challenges to the attention of USAID and worked with AKROS, MoH and USAID to address them.

2. Section 2: Major Accomplishments towards Program Objectives

2.1 Strategic Objective 1: Key determinants of risky behavior reduced among priority populations To reduce key determinants of risky behavior for priority population individuals, the project created demand for high-impact HIV services by employing SBCC interventions. It reached the target priority population with standardized information on protective behaviours and uptake of high-impact HIV services. With the support of these interventions, 156,700 priority population clients completed standardized HIV intervention, with the aim of reducing high-risk behaviours

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and practices and increasing uptake of high-impact HIV services. Result 1:1: Populations at highest risk of HIV acquisition and transmission identified The project identified and reached 156,700 priority population individuals; including 106,380 females (68%) and 50,320 males (32%) with high-impact HIV services. This reach represented 64% achievement towards the FY20 target of 244,821. ▪ Categorization of PP reached

5% PP Reached

NIDUs 26% MMPs PLHIV 51% DCs AGYW Partners 7% AGYW 10% 1%

Of the 156,700 priority populations reached in quarter one of FY20, 51% and 26% were, respectively, AGYW and Mobile and Migrant Populations (MMPs) while 10% and 7% were, respectively, PLHIV and AGYW partners. At 5% and 1%, the least reached were Non-Injecting Drug Users (NIDUs) and DCs (Discordant Couples). It is worthwhile noting that with the passage of time in the implementation of DREAMS, reach to AGYW partners has increased thereby contributing to reaching out with HIV interventions to an elusive sub-population group comprising adolescent boys and men. ▪ Gender-segregation of priority population individuals reached

Gender-segregation of PP reached 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 20-24 25-29 30-34 35-39 40-49 45-49 10-14 yrs 15-19 yrs 50+ yrs yrs yrs yrs yrs yrs Females 21,522 30,305 31,509 9,407 5,853 3,553 2,245 921 1,065 Males 220 4,403 11,265 13,858 8,263 5,336 3,963 1,643 1,369

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The highest number of priority population clients reached were females in the age bands 20-24 (31,509); 15-19 (30,305) and 10-14 (21,522). This reach is attributable to the implementation of DREAMS which focuses on AGYW. There is tremendous improvement in DREAMS reach to older AGYW than in previous years. Initiatives such as Economic Strengthening and Vocational Education sponsorship are pull-factors into DREAMS for older AGYW. In the age bands between 25 and 50 years, the project reached more males than females. Result 1.2: Coverage of appropriately tailored, evidence informed, community- based behavioral interventions significantly expanded Pre-recorded radio programs; community dialogues, one on one conversations carried out by community volunteers (lay counsellors, peer educators, change agents, champions and male positive models) and theatre performances were employed to expand the reach of behavioral interventions. Messages were disseminated on mitigation of risky behaviors; basic facts of HIV, HIV testing, adherence to treatment and correct and consistent use of condoms with the aim of increased understanding of HIV prevention and uptake of high-impact HIV services by the target clients. 1,603 community dialogues were conducted. 19 theatre groups mounted popular performances through which information on high-impact HIV services was disseminated including debunking of myths, beliefs and practices that impede uptake of HIV services.

Result 1.3: Condom accessibility and acceptability improved ▪ Condoms distributed in FY20 quarter one

Condoms distributed in quarter 1

Central Province 777,848

Copperbelt Province 716,310

Livingstone District 6,128

Chipata District 26,300

Lusaka Province 343,404

Lusaka Chipata Livingstone Copperbelt Central Province District District Province Province Condoms Distributed 343,404 26,300 6,128 716,310 777,848

Through the efforts of community volunteers, the project distributed 1,870,026 condoms (1,852,374 male condoms and 17,652 female condoms) to priority population individuals. This represented 59% achievement towards the FY20 target of 3,182,673 condoms. More condoms

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were distributed in the Central and Copperbelt Provinces than Lusaka Province. Distribution of condoms in Chipata and Livingstone was at district level with more condoms distributed in Chipata. Alongside condom distribution, community volunteers disseminated messages on condom use negotiation, and correct and consistent use of condoms.

2.2 Strategic Objective 2: Increase in completed referrals from community programs to high impact services The project employed a two-pronged approach of enabling priority population clients to access high-impact HIV services. Through its cadre of trained lay counsellors, it offered HIV testing in Safe Spaces and distributed condoms and HIVST kits to target clients. The project also mobilized community volunteers made up of mentors, peer educators, lay counsellors, change agents and champions to identify priority populations using a risk-tool and refer them to health facilities for HIV services. The outcome was increased uptake of HIV services by the target priority population. Result 2.1: High-impact services promoted High-impact services were promoted through Safe Space activities in community meeting points and DREAMS Centers and also through SBCC interventions of popular theatre performances, community dialogues and inter-personal conversations; all with the aim to increase demand for and uptake of services by target clients. ▪ HTS reach and positivity USAID Z-CHPP provided HIV testing services and results to 6,288 priority population individuals (4,870 females and 1,418 males). This represented achievement of 95% towards the HTS target of 6,597 for FY20. 1,074 clients (17%) (638 females and 436 males) were found positive and referred for ART out of which 1,050 (98%) Positivity by service modality initiated treatment. 50%

40% 897 clients were identified and tested Index, 40% 30% using index testing services, Mobile, 31% 20% representing achievement of 66% 10% towards the annual target of 1,360 for VCT, 2.3% 0% FY20. 40% of positive clients were INDEX MOBILE VCT found through index testing while 31% and 2.3% were, respectively, identified through mobile and VCT modalities. With and without DREAMS, the positivity rate was 17% and 31%.

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▪ Positivity without DREAMS

Positivity without the DREAMS component

1,200 1,064 36% 977 942 Dec-19, 36% 1,000 Nov-19, 33% 35% 34% 800 Oct-19, 32% 33% 600 338 324 335 32% 400 31% 200 30% - 29% Oct-19 Nov-19 Dec-19 Oct-19 Nov-19 Dec-19 Tested 1,064 977 942 Positive 338 324 335 Positivity 32% 33% 36%

Without DREAMS, HIV positivity rate ranged from 32% in October through 33% in November to 36% in December. ▪ Positivity with DREAMS

Positivity with the DREAMS component 3,000 30% 2,357 2,179 1,752 2,000 21% 20% 15% 16% 1,000 370 345 359 10% - 0% Oct-19 Nov-19 Dec-19 Oct-19 Nov-19 Dec-19 Tested 1,752 2,357 2,179 Positive 370 345 359 Positivity 21% 15% 16%

With the component of DREAMS added, HIV positivity rate ranged from 21% in October through 15% in November to 16% in December. As reflected on the first graph on HIV positivity, the project sustained increased positivity yield in quarter one of FY20. This shows the knowledge, skills and experience invested into and gained by project lay counsellors payed dividends as they:

▪ Consistently used the risk assessment tool to determine most at-risk clients before HTS; ▪ Placed emphasis on index testing over other modalities; ▪ Worked with facility staff to get information on, track and index-test high viral load clients.

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▪ HTS uptake among priority population sub-groups

Population category and positivity yield 4,500 4,088 4,000 3,500 3,000 2,500 1,910 2,000 1,500 1,000 764 250 500 108 36 50 18 132 9 0 AGYW & Discordant MMP NIDUs Others partners Couples Tested 4,088 108 1,910 50 132 HIV+ 250 36 764 18 9 Positivity 6% 33% 40% 36% 7% Linked 249 36 739 17 8

▪ Positivity among AGYW and Sexual Partners

AGYW Vs sexual partners positivity 3500 3000 2500 2000 1500 AGYW Sexual Partners, 1000 175 AGYW, 75 500 0 AGYW Sexual Partners AGYW HIV Tested 783 3,305 HIV+ 175 75 Linked 174 75

Due to the implementation of the DREAMS, the highest priority population sub-group that was HIV tested were AGYW and sexual partners followed by mobile populations. Fewer numbers of Discordant Couples, NIDUs and the ‘Others’ category were tested. The highest rate of those found positive and linked to treatment were the mobile and migrant populations. The lowest rate of those found positive was among AGYW. However, when AGYW sexual partners’ data is analyzed separately without factoring in AGYW data, it shows there is high positivity of 22% among the AGYW sexual partners signifying a worrisome trend of high-risk sexual behavior among AGYW. 175 AGYW sexual partners were found positive out of 783 that were HIV tested while only 75 AGYW (2%) were found positive out of 3,305 AGYW tested. This speaks of the need for continuous

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and consistent messaging on dangers of high-risk behavior, need for condom negotiation and consistent and correct use of condoms by AGYW and the need for assertiveness in relationships between AGYW and sexual partners. Positivity and linkage of priority population clients reached, by gender

Positivity and linkage among priority population clients 100% 80% 13% 638 623 98% 60% 4,870 40% 31% 20% 436 427 98% 1,418 0% HIV tested HIV +ve Positivity Successfully linked Linkage rate Female 4,870 638 13% 623 98% Male 1,418 436 31% 427 98%

This analysis shows that project focus on mobile populations should not stop because most positives are found in this population sub-group. A major achievement of USAID Z-CHPP has been the capacity to reach mobile population clients in targeted hotspots through efforts of trained community volunteers. Of the females tested, the high number of those found positive was among the mobile population who were tracked and tested in hotspots. Of the 4,870 females tested, 638 were found positive out of which 623 were initiated on treatment representing a linkage rate of 98%. For the 1,418 males tested, 436 were found positive with 427, representing a linkage rate of 98%, linked to treatment. The project witnessed higher linkages due to increased efforts of client follow-ups and escorted referrals. This has contributed to the reduction of new HIV infections in Zambia. For USAID Z-CHPP, this was a thematic area of presentation in the ICASA Conference held in Rwanda in November 2019. ▪ HIVST ▪ HIVST kits distributed in quarter 1 of FY20

30,520

9,976 5,334 137

HIVST Kits

Target Distributed Q1 PP reported back HIVST Positives

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9,976 HIVST kits were distributed representing 33 % of the annual target of 30,520 kits to be distributed in FY20. 742 HIVST kits were distributed through DREAMS Centers. 3,601 and 2,800 clients respectively received the kits through assisted and unassisted service modalities. 5,334 individuals reported back the results with 137 reporting HIV positive results. The ones that reported the positive results were referred for confirmatory testing. Of this number, 106 were assisted while 31 were unassisted.

Distribution of kits to females and males

1,821

1,292 1,151 1,085 834 686 667 655 20 3 188 392 204 425 79 227 80 167 10-14 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-44 45-49 50+ Female 20 686 1,821 1,151 834 392 204 79 80 Male 3 188 667 1,292 1,085 655 425 227 167

Females in the age groups 20-29 and males in the age gr0ups 25-34 constituted the highest number of HIVST kits recipients. Result 2.2: Linkage between community and facility-based services strengthened The project worked and mutually collaborated with 102 MoH health facilities in five provinces and 14 districts to ensure priority population clients accessed high-impact HIV services. This comprised: ▪ Sourcing of health commodities such as sharp boxes, HIV test kits and condoms from health facilities by the project; ▪ Referring priority population clients to health facilities for high-impact HIV services; ▪ Weekly attachment of MoH facility-based nurses to 40 DREAMS Centers to offer services such as family planning, STI screening, HIV testing and referrals for Post Gender-Based Violence (PGBV) care; ▪ Holding of monthly meetings with MoH staff in health facilities on data; referrals and linkages to high-impact services. Result 2.3: Community-based delivery of selected high impact services facilitated The project delivered community-based high-impact services of: HIV testing and referrals for care; condom distribution and condom use education; screening for HTI and referrals for PGBV care, PREP, PEP and VMMC; HIV prevention education and SBC messaging on high-impact

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services. Delivery of selected community-based high-impact services was done through the agency of community-based volunteers who were supported by the project. Result 2.4: Referrals to high impact services tracked and documented USAID Z-CHPP tracked and documented referrals to high-impact services through use of referral slips, project registers, facility registers and the DHIS2 database. Weekly site meetings were held involving project staff, community volunteers, lay counsellors and health facilities staff to check the quality of data and to strengthen the use of referral documentation. Monthly data verification exercises and routine data quality assessments (DQAs) were conducted to check data reliability and quality. 2.3 Strategic Objective 3: Actions adopted by communities to reduce young women’s vulnerability to HIV, unwanted pregnancy and SGBV The project used its Safe Space model of delivering high-impact HIV services to demonstrate to communities actions that reduce young women’s vulnerability to HIV, unwanted pregnancy and SGBV. AGYW accessed services of HIV prevention, family planning, education and economic strengthening through the Safe Spaces. Outcomes included increased understanding of actions that reduce young women’s vulnerability and reduced AGYW vulnerability to HIV, unwanted pregnancy and SGBV. Result 3.1: Community awareness of factors influencing young women's vulnerability increased Through exposure to and participation in DREAMS activities, awareness increased around AGYW vulnerabilities in the 40 communities where DREAMS is implemented. The project employed radio programs, community dialogues and interactive theatre to broadcast AGYW vulnerabilities and how these can be mitigated. Communities participated in DREAMS by enrolling AGYW into DREAMS. The project operated Safe Spaces through which AGYW accessed services as summarized: ▪ Operations of Safe Spaces

AGYW screened, enrolled and graduated in FY20 quarter 1 Vs annual targets for FY20

Graduated, 49,519 166,667 Screened, 59,117 Enrolled, 57,429 150,000 135,000

Screened Enrolled Graduated Target 166,667 150,000 135,000 Reached 59,117 57,429 49,519

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AGYW were identified, screened, enrolled into the DREAMS program and assigned to Safe Spaces where they received high-impact HIV, educational and economic strengthening services. 59,117 AGYW were identified and screened out of which 57,429 (97%) were enrolled into the program. The majority of the enrollees were in the age range of 15 to 19 at 39% (22,604); while 20,764 (36%) and 14,061 (25%) were enrolled into the program in the age ranges of 10-14 and 20-24, respectively. By the end of quarter 1 of FY20, 49,519 AGYW successfully graduated from the program having successfully completed the Stepping Stones course; accounting for 86% of those enrolled. 40 DREAMS Centre managers, 122 connectors and 554 mentors managed DREAMS Centers, conducted Safe Spaces and facilitated delivery of services to AGYW and sexual partners. Services offered included HIV prevention education; HIV testing and referrals for ART; STI treatment; PSGBV care and PREP; condoms; family planning, economic strengthening and educational support. ▪ Access to services by AGYW HIV prevention education, access to condoms, HIV testing and referrals for services All the 57,360 AGYW enrolled into DREAMS completed a standardized HIV prevention intervention package which is based on evidence and meets required minimum standards. AGYW were encouraged to know their HIV status and that of sexual partners. 3,305 AGYW were HIV tested with 76 testing positive. These were referred for treatment out of which 75 initiated treatment. ▪ Age cohort with highest positivity

Age Cohort Positivity

10-14 7.89%

15-19 17.1%

20-24 75%

Of the AGYW that tested positive, 75% were in the age range of 20-24. The older AGYW get, the more vulnerable they become to HIV, unwanted pregnancy and SGBV. Cognizant of this, the project ramped up efforts to increase the recruitment of AGYW in the age range of 20-24 as demonstrated in quarter 1 of FY20 where 14,056 of this age range were recruited. In the past, this was a difficult age group to reach and recruit but with the expansion of economic strengthening initiatives such as short-term vocational training sponsorship and the addition of the School-

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Based Prevention Initiative (SBPI), the project is witnessing the recruitment of higher numbers of AGYW of this age range into DREAMS. While not neglecting the other age cohorts, the project has also tailored its HIV messaging with particular focus on the need for AGYW self-belief, confidence, focus on school for those still in school, dangers of high-risk behavior, need for condom negotiation and consistent and correct use of condoms for AGYW that are sexually active and the dire need for assertiveness in relationships with sexual partners. ▪ Family Planning 4,643 AGYW accessed family planning services with 2,188 (47%) accessing Depo Provera; 1,281 (28%) accessed combined oral contraceptives; 1,133 (24%) accessed condoms and 41 (1%) accessed Jadelle. On weekly basis throughout the quarter, MoH nurses worked in DREAMS Centers to provide family planning services to AGYW. Provision of services was preceded by counselling on family planning and HIV and information given to AGYW on how to deal with incidences of SGBV. Dual protection (protection from both HIV and unwanted pregnancy) was emphasized for AGYW not using condoms as a family planning method. ▪ Access to family planning services

Access to family planning services in quarter 1 of FY20

2,188

1,281 1,133

41 Condoms Oral Contraceptives Jadelle Depo Provera FP Services 1,133 1,281 41 2,188

▪ OVC Support The project supported 35,169 OVC with services of education, economic strengthening; family planning; HIV prevention education; HTS and referral for care for those found positive and PSGBV care and psychosocial support. This achievement represented 34% of the annual target of 103,591. ▪ School-Based Prevention Initiative The project worked with 312 schools to promote reduction of HIV, unwanted pregnancy and SGBV among AGYW in schools. School administrators, teachers, career and guidance teachers and Adolescent Boys and Young Men (ABYM) were mobilized and supported to implement and participate in activities of SBPI. Activities of the initiative included: conducting school-based safe

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spaces where AGYW received HIV education, were provided information on SGBV prevention and PSGBV care and were referred to DREAMS Centers and health facilities for high-impact HIV services. The project trained school-based Anti-GBV champions (ABYM) who addressed SGBV in schools by conducting 341 SGBV dialogues that included meetings and debates in school halls. The project supported schools to conduct extra-curricular activities of debates, games such as athletics, spelling bees, drama and career fairs as a means of promoting and disseminating information on HIV and SGBV prevention among school boys, school girls and teachers. Bursary and scholastic support were provided to most vulnerable 16,400 AGYW in form of tuition fees, uniforms and books. ▪ DREAMS primary package service completion in quarter 1 of FY19

AGYW primary service completion 89% 90% 85% 84% 88%

23% 20% 13% 3%

Completed more than Primary Completed 1 Service Completed Primary Package Package 10-14 85% 84% 3% 15-19 89% 88% 20% 20-24 90% 23% 13%

The project provided layered services to 57,429 AGYW enrolled into DREAMS. Service provision was done through DREAMS Centers, centrally located Safe Spaces and through active referrals. Services uptake was as follows: 1. In the 10-14 AGYW age cohort, 85% completed 1 service. 84% completed the primary package and 3% completed more than primary package. 2. In the 15-19 AGYW age cohort, 89% completed 1 service, 88% completed the primary package and 20% completed more than primary package. 3. In the 20-24 AGYW age cohort, 90% completed 1 service, 23% completed the primary package and 13% completed more than primary package. Completion of 1 service refers to any service from the DREAMS core package of services where: The primary services are safe spaces (social asset building) for the 10 to 19-year-old AGYW and social asset building + HTS + condoms for the 20-24 age cohort.

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Completion of the primary package refers to additional access to services in the secondary category that includes services of contraceptive mix, post violence care, educational subsidies financial literacy training, enrolment in savings groups, vocational training and the parenting program. With the rigorous use of the risk assessment tool in HIV testing of AGYW, few AGYW were eligible for HIV testing. This led to only 3% of AGYW completing more than the primary package as the majority were not eligible for HIV testing. Result 3.2: Highly vulnerable young women linked to economic strengthening interventions to reduce transactional and age disparate sex As economic strengthening support, 5,237 AGYW were trained in savings. 190 savings groups were formed out of which 154 were formed in DREAMS. 10 savings groups were linked to FINCA for microfinance support. 33 in-kind business start-up kits were distributed to 183 AGYW who were supported to form business groups and begin running business. The kits distributed were for micro business in the areas of cookery, baking, tailoring, and arts and crafts. Through the Kozo initiative, 220 AGYW were equipped with knowledge and skills of designing, cutting and making of re-usable sanitary pads. Pact and Plan are working with sub-partners and AGYW engaged in Kozo to improve the quality of the sanitary pads and streamline the sales.

Key outcomes of the economic strengthening support to AGYW included: enhanced appreciation of savings by AGYW; increased participation in savings groups and increased engagement in microbusiness initiatives by AGYW. These are important outcomes as they put AGYW on the pathway to empowerment and lessened exposure to vulnerability.

For the remaining period of project implementation, Pact is working with sub-partners to focus on increasing AGYW ownership and sustainability of ES activities.

2.4 Strategic Objective 4: Strengthened capacity of local stakeholders to plan, monitor, evaluate and ensure the quality of prevention interventions Pact provided organizational, technical and financial support to stakeholders to strengthen capacity for effective and impactful implementation of HIV prevention interventions in 14 districts where the project is implemented. This resulted in enhanced, unified and coordinated response to HIV thereby contributing to reducing new HIV infections in Zambia.

Result 4.1: Organizational and technical capacity of community structures and stakeholders enhanced ▪ Support to sub-partners ▪ CMMB 2016 scores compared to 2019 scores

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Capacity area CMMB 2016 CMMB 2019 Adequate infrastructure 45 42 Quality service delivery 54 44 Institutional policies 35 53 Human resource management 42 47 Community engagement 64 60 Resource mobilization and sustainability 64 59 Governance and leadership 45 57 Partnerships and advocacy 40 50 SBCC 58 70 Finance and administration 51 53 Monitoring and evaluation 36 38

Pact conducted Integrated Organizational Capacity Assessment (ITOCA) for CMMB. The self- assessment results revealed improvement in most capacity areas, when compared to the 2016 results. Pact will continue to work with CMMB in areas where it is facing challenges. Pact held bi- monthly Institutional Strengthening Plan (ISP) tracking meetings with CMMB, YWCA, SIA and ZHECT. The three organizations were above 60% in the implementation of ISP items for the quarter. ▪ Support to Government stakeholders The project supported NAC and 14 DHACS commemorate WAD in December 2019 whose theme was “Communities Make a Difference; Pressing towards Ending AIDS”. The project support included creating demand for high-impact HIV services through drama performances, targeted HIV testing through use of a risk assessment tool and distribution of condoms and HIVST kits. Pact supported Livingstone DHAC conduct a Community Performance Index (CPI) assessment with a view to assess the district’s community HIV response effectiveness, identify gaps and prescribe solutions for bridging the gaps. Following the CPI assessment, Pact supported the district develop a Community Strengthening Plan (CSP). Result 4.2: Project evaluation systems strengthened to inform project implementation To ensure efficient and impactful USAID ZCHPP implementation through strengthening of the project monitoring and evaluation system, Pact conducted/carried out: 1. Orientation training and meetings for sub-partners’ Data Associates, Mentors, Connectors and DREAMS Center Managers and Lay Counsellors on the management and use of the risk assessment tool, use of registers for HIVST and index testing data entry into the DHIS2 data base.

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2. Monthly data verifications in all project sites to ensure the reliability and integrity of data and that only jointly verified data was reported. 3. Outcome review of the outcome assessment tool which is used for capturing of individual data on AGYW and assessment of DREAMS impact on AGYW. Pact M&E Officers worked with Data Analysts to orient DREAMS Center Managers and selected mentors on the administration of the tool. 4. SmartCare Lite roll-out in Lusaka District: Following months of preparations including holding of meetings with USAID BroadReach IT department and the Lusaka Provincial Health Office, the Pact M&E team worked with project lay counsellors to roll-out SCL in Lusaka sites. In collaboration with health facilities in project sites, the project is using SCL as a tool for tracking priority population clients’ health records, continuity of care and for reporting. The M&E team is providing continuous support to lay counsellors on the use of SCL. Actions undertaken to strengthen the project evaluation systems resulted in increased M&E knowledge and skills of sub-partners’ staff engaged in project M&E such as M&E Officers, Data Clerks and Lay Counsellors. This led to production of accurate and quality data for project reporting, decision making and for guiding project implementation. Result 4.3: Coordination of local-level prevention response in project areas Pact through USAID ZCHPP coordinated the implementation of DREAMS in all districts where DREAMS is implemented. Monthly coordination meetings were held to monitor, review and evaluate performance. DREAMS partners shared and compared notes on achievements, challenges and opportunities for improvement. The project also supported sub and district level coordination meetings where the response to HIV was discussed, evaluated and opportunities for improvement explored. State and Non-State actors that attended the meetings included District Local Authorities; District Ministry of Health Authorities; District Ministry of General Education Authorities, six sub-partners, Peace Corps and USAID partners such as STOP GBV, ZAMFAM, DISCOVER H, Breakthrough Action and SAFE.

3. Section 3: Cross-Cutting Activities and Updates

1. High level visits In December 2019, the US Ambassador to Zambia and the Peace Corps Director visited Main DREAMS Centre to familiarize themselves with the operations of the Center in preventing HIV, unwanted pregnancy and SGBV among AGYW.

2. Human resource, financial and sub-awards management

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Pact effectively managed its human resources, finances and sub-awards which resulted in the successful implementation of the project. The project filled the vacancies of HIV Technical Officer for Lusaka Province and the HIV Prevention Technical Advisor in November and December of 2019. 3. Summary financial report Total Estimated Year 1,2,3,4 & This Period Previously Inception to Amount Year 5 Total Obligated Actual Expenditure this Expenditures Reported Date Balance of S/NBudget Categories (US$) Budget Amount(US$) Period (US$) (US$) Expenditures Expenditures Balance of Total Oct - Dec (US$) (US$) as at 31st Obligated Estimated ZCHPP DREAMS FCI 2019 December 2019 Amount (US$) Budget (US$) 1 Personnel 6,048,496 5,604,501 163,257 169,004 637 332,897 4,118,301 4,451,199 1,597,297 2 Fringe Benefits 2,936,375 2,451,695 50,718 62,967 1,120 114,805 1,503,398 1,618,202 1,318,173 3 Allowances 732,802 651,748 2,087 3,395 1 5,483 440,313 445,796 287,006 4 Travel 915,895 613,425 16,444 25,764 577 42,786 380,256 423,041 492,854 5 Equipment 422,206 422,206 - - - - 422,206 422,206 0 6 Supplies 620,797 620,797 1,089 8,653 449 10,192 590,387 600,579 20,218 7 Consultants 51,718 13,934 - - - - 7,319 7,319 44,399 8 Project Activities 6,565,307 7,422,587 30,673 266,787 2,569 300,029 5,331,979 5,632,008 933,299 9 Subawards 31,350,328 27,976,105 355,597 900,631 48,800 1,305,028 22,227,000 23,532,028 7,818,300 10 Other Direct Costs 2,089,340 2,044,024 11,618 66,672 3,434 81,724 1,473,286 1,555,010 534,330 11 Total Direct 51,733,264 47,821,021 - 631,483 1,503,873 57,588 2,192,944 36,494,444 38,687,387 13,045,877 12 Indirect Costs 8,266,595 8,417,896 106,290 238,758 5,297 350,345 5,800,147 6,150,492 2,116,103 13 Total Budget 59,999,859 56,238,916 56,978,388 737,773 1,742,631 62,885 2,543,289 42,294,590 44,837,879 12,140,509 15,161,980 14 Expected Cost Share Amount 2,999,930 2,811,946 249,548 2,519,614 2,769,162 230,768 15 Total Program Amount 62,999,789 59,050,862 56,978,388 737,773 1,742,631 62,885 2,792,837 44,814,205 47,607,042 12,140,509 15,392,747 At the beginning of the quarter, the FY20 Budget of $13,944,326 was fully obligated with an additional obligation amount of $11,539,942. This brought the total obligation to $56,978,388. As shown in the table above the expenditure incurred in this first quarter amounted to $2,543,289 bringing the total expenditure to date from inception to $44,837,879. This represents 75% of the total estimated budget amount and 79% of the total obligated amount. The quarterly expenditure was slightly below the projected figures partly due to the slow start of program implementation of newly introduced Faith-based Community Initiative (FCI) and the protracted discussions on the mode of implementing the Families Matter component under DREAMS. The exchange rate gains also played a part as the lost value against major currencies during the period under review. However, the implementation efforts and the burn rate will be scaled up in the second quarter in order to make up for lower expenditure levels in this quarter.

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▪ During this period $249,548 was contributed as cost share bringing the total cost share from inception to date to $2,769,162. The is represents 92% of the cost share budget of $2,999,930. ▪ The subaward agreements with all the six local partners (CHEP, CMMB, SIA, YWCA, ZCCP & ZHECT) and the International partner, Plan International were modified to extend their program implementation for this financial year. Their FY20 Budgets were also fully obligated. In this period sub-partners were all funded on time to facilitate implementation of activities. ▪ As FY20 is the final year for the project, 2 close-out meetings were held with sub-partners to sensitize them on project close-out requirements and drawing up of close-out plans. Desk Reviews were conducted for sub-partners and support was provided to ensure effective program financial management. In order to strengthen financial management, through monthly desk reviews and onsite field monitoring visits, 3 Grants and Contracts officers were recruited to replace 2 who left during the period. 4. Environmental mitigation and monitoring plan implementation The project complied with USAID environmental mitigation protocol as it successfully implemented its revised Environment Mitigation Monitoring Plan (EMMP). It ensured used HIV test kits, condoms, sharps and any materials used in HIV testing were handled and disposed correctly. Expiry dates on HIV test kits and condoms were monitored to ensure commodities used were not expired. The project frontline staff were consistently reminded of the requirements of the environmental mitigation protocols including safety on handling bio-medical waste. Lay counsellors, who conduct HTS, wore appropriate gear and used disposal containers to avoid contamination with waste. Generated waste was handed over, in appropriate containers, to health facilities for disposal in line with MoH procedures.

4. Section 4: Challenges and Opportunities for Improvement

The matrix below shows key challenges faced in quarter 1 of FY20 and actions taken by the project to resolve them:

No. Key Challenge Action Taken Difficult access to Pact brought this challenge to the attention of USAID condoms and HIVST kits Zambia and MoH who are, respectively, supporting and 1 slowed down pace of managing the health commodities supply chain to resolve implementing HIV the stock outs of condoms and HIVST kits prevention activities Data entry, cleaning and The project contacted the DHIS2 developer to resolve the 2 reporting affected by system challenge and remove the duplicates DHIS2 system challenges

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of duplicates appearing in the system Delayed data entry into The project purchased internet Mifi for DREAMS Centres 3 data base due erratic that enabled staff access internet during periods of power power supply cuts Delayed roll-out of The project directly linked its tablets to the SMARTCARE SMARTCARE LITE due to 4 facility in Health Facilities which enabled roll-out of SCL incompatibility of tablets without use of card readers and card readers Non-implementation of This challenge was brought to the attention of USAID parenting program due to Zambia who advised change of program. In quarter 2, the 5 complications of FMP project will set up and implement another parenting start-up program called SINOVUYO

5. Section 5: Highlights of FY20 Quarter 2 Activities

1. Implement SBCC activities 2. Conduct HIV prevention activities including HIVST implementation and training 3. Set up and implement the DREAMS parenting program 4. Facilitate provision of layered services to AGYW 5. Implement SBPI, FCI, ES and SGBV activities 6. Coordinate implementation of DREAMS 7. Conduct organizational and technical capacity strengthening activities 8. Hold technical review meeting 9. Finalize SmartCare roll-out in Lusaka, Central and Copperbelt provinces 10. Conduct data verifications and audits 11. Conduct M&E training for staff and volunteers 12. Manage the DHIS2 data base and produce reports 13. Finalize close-out plans with sub-partners 14. Conduct financial management desk reviews 15. Conduct finance and operations monitoring/compliance through on-site visits

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SUCCESS STORY A fresh start for Charity through DREAMS Aged 24, Charity is in the older age cohort of the DREAMS program. She is making a fresh start in life. She lives in Chipata City, which is the Vulnerable, naïve only city in the rural Eastern Province of Zambia. It is a cramped and and out of school, densely populated city flanked by hills giving it a scenic look. It is in the Charity hit rock densely populated, low-income and sprawling area of Chipata called Muchini where Charity makes her home. She has lived all her life in bottom only to be Muchini. She sells food products, mostly different kinds of dry beans, rescued by the at a market called Kaumbwe. But life has not always been like this for DREAMS Program Charity. in Chipata Recollecting, Charity remembers with sadness that her world caved in when she failed to qualify for senior secondary school. She was then at the tender age of 17 when she fell through the education crack and found herself in the dusty streets of Muchini. As poor as a church mouse, her father could not put her back into school. With no mentor, naïve and relentlessly pursued by irresponsible young and older men, it was not long before she began to engage in high-risk sex. The result was pregnancy and entry into unplanned motherhood at the tender age of 17.

Out of school and a mother at a tender age, Charity became a stench in the nostrils of her parents who neither looked after her nor her child. Vulnerable and in need of food for herself and her child, Charity soon found herself in a shaky abusive marriage. It did not take long before

she found herself with a second child. With two children to look after, “If it was not for the life became even harder. It was at this low ebb when she heard of DREAMS program, I DREAMS. She approached a mentor called Selina who wasted no time would have died of in enrolling her into DREAMS where she completed the Stepping Stones course, joined a savings group and accessed family planning and depression” HIV prevention services. Fast forward to December 2019, Charity is an Charity, Chipata empowered, financially independent and resilient young woman who is running her own business. She is now in her second cycle of saving and can feed her two children. “DREAMS gave me life” says Charity. DREAMS is a component of the PEPFAR funded USAID Zambia Community HIV Prevention Project implemented in 8 including Chipata.

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SUCCESS STORY Safe and protected through PrEP Thanks to a DREAMS Safe Space, Carol, not her real name,

is on Pre-Exposure Prophylaxis (PrEP). Though not HIV

positive, she takes ARV drugs to protect herself from being infected with HIV as she is in a very high-risk sexual relationship. Aged 20 and a young mother with a child who

is one year three months old, Carol has now been on PREP for four months. ” I’m happy I’m on PREP because now I know I Her pathway to PrEP started when the topic on high-impact don’t have to worry about HIV services including HIV testing and PrEP were discussed being infected with HIV. I in the Safe Space meeting she attends for the 20 to 24-year- have been taking the old DREAMS enrolees. Led by a Mentor and attended by drugs for 4 months now. young women, the Safe Space meeting was held in a secure At first, I was not sure I space, away from prying eyes and peeping Toms, in one of would continue because I the bustling, low-income and densely populated township in was skeptical about the Lusaka. whole idea of taking At first, Carol was reluctant to join the Safe Space. However, drugs every day. attendance of one session led to attendance of another. However, I am used to the Eventually, it happened as she became a full member of the routine and I know it’s for Safe Space participating in a Stepping Stones course. It was my own benefit, am only then that she warmed up to the friendly Mentor and happy I am HIV negative divulged information on her sex life and the high-risk and I intend to keep it that relationship she was trapped in. She was HIV tested and way” found negative. Armed with information on PrEP, she opted

for it. Carol, Lusaka “PrEP is helping me deal with anxieties as my partner is stubborn. He will not hear of protected sex and will never agree to HIV testing even through HIV self-test kit.”

The Safe Space Carol attends is organized by the PEPFAR funded USAID Zambia Community HIV Prevention Project.

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SUMMARY INDICATOR TABLE

(a) (b) (c) (d) FY20 Achieved this Achieved to- % achieved to- Objectives/Indicators Annual quarter date date ((b/a) Target X100)

SO1: Key determinants of risky behavior mitigated among priority populations Number of individuals from priority populations who completed a standardized HIV prevention intervention, including the specified minimum components during reporting 244,821 156,700 156,700 64% period (PP_PREV; PEPFAR Required) Number of male and female condoms distributed to end users during the last 12 months 3,182,673 1,870,026 1,870,026 59% Number of priority population individuals reached through community theatre on 75,600 43,085 43,085 57% SGBV/gender/cultural norms and HIV prevention Number of FBO leaders trained in HIV prevention and SGBV 350 237 237 68%

SO2: Increase in completed referrals from community programs to high impact services Number of individuals who received HTS services and received their best results during 6,597 6,288 6,288 95% the reporting period (HTS_TST; PEPFAR Required) Number of Individuals who were identified and tested using index testing services and received their test results (PEPFAR Indicator) 1,360 897 897 66% Number of HIV self-test kits distributed 30,520 9,976 9,976 33% Percent of successful (complete) referrals for HIV-related services. 95% 98% 98% 98%

SO3: Actions adopted by communities to reduce young women’s vulnerability to HIV, unintended pregnancy and SGBV Number of AGYW enrolled in DREAMS and currently in safe spaces 150,000 57,429 57,429 38% Number of active beneficiaries served by PEPFAR OVC programs for children and 103,591 35,169 35,169 34% families affected by HIV/AIDS Number of orphans and vulnerable children (<18 years old) with HIV status reported to implementing partner (including result not reported), disaggregated by status type. 88,308 31,936 31,936 36%

Number of adolescent girls and young women (AGYW) ages 10 – 24 enrolled in DREAMS 135,000 49,519 49,519 37% and attended full safe spaces program Number of beneficiaries trained in savings skills (WORTH and OSAWE 8,400 6,215 6,215 74% Number of saving groups (OSAWE/WORTH) formed 363 204 204 56% Number of Students who received bursary support 8,500 9,255 9,255 109% Number of Students who received Education Materials 8,500 7,145 7,145 84%

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SO4: Strengthened capacity of local stake holders to plan, monitor, evaluate and ensure the quality of prevention interventions. Number of partners who have Organizational Performance Index Assessments (OPIs) 6 0 0 0% undertaken Number of partners who have implemented a minimum of 60% of their ISPs 6 6 6 100% Number of verifiable supportive supervisory and/or mentoring visits provided to 24 4 4 17% partners Number of partners who have shown improvement in their organizational performance 6 6 6 100%

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