Meeting Targets and Maintaining Epidemic Control (Epic) Project

Meeting Targets and Maintaining Epidemic Control (EpiC) Project

Cooperative Agreement No. 7200AA19CA00002

ESWATINI SEMI-ANNUAL PROGRESS REPORT OCTOBER 1, 2020 TO MARCH 31, 2021

SUBMITTED BY FHI 360: MAY 20, 2021

EpiC Eswatini Semi-Annual Progress Report October 1, 2020 to March 31, 2021

A. Executive Summary Key Population (KP) programming transitioned from LINKAGES to EpiC at the start of FY21. Programming continued to be dynamic adjusting to the COVID-19 status in country, which included a second wave from mid-December 2020 through the end of February 2021. EpiC Eswatini formally began programming with two new key populations (KPs): transgender persons (TG) and people who inject drugs (PWID). Focus for both includes access to basic clinical services, as well as advocacy to expand the current enabling environment to allow for more specialized services and development of targeted programs. EpiC conducted a high-level TG Stakeholder meeting, including the TG community, Ministry of Health (MOH), Deputy Prime Minister’s Office, Royal Eswatini Police Services, USAID/Eswatini and USAID/Southern Africa, a health care worker who supports gender affirming care (informally) and UNAIDS. This meeting provided approval to develop a TG strategic plan with the Ministry of Health. The program continued to expand services to the KPIF implementing partners1 including transitioning of all psycho-social services (PSS), TG demand creation, as well as worked to transition all Female Sex Worker (FSW) outreach workers, which will be finalized in April 2021. On the service provision side, the program focused on the introduction of decentralized drug distribution (DDD) for both ART and PrEP through home-based appointments, as well as expanded services to include viral load testing, starting in January 2021. Detailed achievements for this program are presented in Section I of this report. The National Emergency Response Council on HIV and AIDS (NERCHA)2 program transitioned to EpiC from the prior USAID project HC4 and received equipment and vehicles in November 2020. Eight staff were hired and trained on data management using Community Data Action Platform (CDAP) in November 2021, with the Strategic Information Advisor starting in December 2021. As programming was ramping up, Eswatini began experiencing the start of the second wave mid-December, which was impacted by the identification of the South African variant B.1.351. Routine programming was only able to return on second week of March 2021 when the government relaxed its restrictions on movement and meetings at the community level. COVID-19 impacted and delayed program implementation as most activities require face to face meetings and trainings to capacitate community leadership on the program. Detailed achievements for this program are presented in Section II of this report. Under the EpiC consortium partner PSI, 4,506,000 male condoms were distributed, of which 56 percent went to retail outlets and 44 percent to partners. PSI continued to promote condom access and use on social media and radio. Condom sales continued through the self-sustainable model developed with PSI/South Africa (SA). An increase of 33 percent in condom sales was seen during the shift from the integrated retail distribution model to the full commercial self-sustainable model. Commercial lubricants were introduced to the product portfolio, further providing choice and convenience to consumers. Detailed achievements for this program are presented in Section III of this report. The report is organized as follows: • Section I: Key Populations Program – page 2 • Section II: EpiC Eswatini/NERCHA: Community Strengthening Program – page 38 • Section III: EpiC Eswatini Condom Program – page 52

1 HealthPlus 4 Men, House of Our Pride, Rock of Hope and Voice of our Voices 2 National Emergency Response Council on HIV and AIDS (NERCHA) was created to coordinate and facilitate the National Multisectoral HIV/AIDS response and oversee the implementation of the national strategic plans and frameworks in the Government of the Kingdom of Eswatini.

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Section I: Key Populations Program

B. Key Results by Objective

1. Attain and maintain HIV epidemic control among at-risk adult men, women and priority populations (PP)

Men who purchase sex (MWPS)3 is a target group under the EpiC Key Population Investment Fund (KPIF), which is implemented through the EpiC Eswatini project. KPIF focuses on demand creation for identified populations that are at risk in Eswatini, and the EpiC Eswatini project provides clinical services thus the reporting below only captures those reached with clinical services.

Under the KPIF program, through Voice of our Voices our FSW-led partner, FSW peers mobilized their clients to access services as follows: ▪ 70 MWPS, of which 50 are transport operators (TOPS), were provided with clinical services and 66 MWPS that were eligible received HIV testing and results, two tested positive and was initiated on treatment, for a three percent case finding rate. ▪ Reaching MWPS has been a challenge during COVID-19 as hotspots were closed, which was the primary way to access and to refer them to services. ▪ Most MWPS have been reluctant to access services at the community center hence marketing the space will be done to improve access, especially for TOPs, who are reached primarily as MWPS.

EpiC consortium partner PSI leads on national level condom programming technical assistance. Activities and accomplishments under the condom programming are reported in Section II.

3 Previously referred to as Clients of Sex Workers (CSW)

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2. Attain and maintain HIV epidemic control among key populations (KP)

Female Sex Workers (FSWs) Reach (KP_PREV)4 A total of 5,711 FSWs have been reached with prevention package of services. This accounts for 56 percent (5,711/10,284) of the annual target. A total of 52 percent (2,963/5,711) were known positive of which 1,418 accessed community level services such as as-one-on one discussion or were given condoms and lubricants but did not access clinical services. 4,293 FSWs, or 75 percent of all FSWs reached, accessed our clinical services. Of those that accessed our clinical services 1,898 accessed testing services, 1,545 were known positive (included in the 52 percent noted above), 6 declined and 844, or 15 percent (844/5,711) were not due for testing but accessed non-testing services. The program implemented an EPOA in the first quarter of the year, identifying 15 female sex worker seeds, ten were through EpiC with five additional seeds identified through the Key Population Investment Fund (KPIF), to facilitate mobilization and inject new networks to the outreach workers. Impacts relating to COVID-19 are captured under the enhanced development of sustainable prevention programs section that focused on the peer outreach and demand creation aspect of the program. FSW accessing testing services and case finding: Of the 1,904 FSWs that were eligible5 for testing, 99 percent or 1,898 tested 6 , and six declined testing services. This has accounted for 113 percent (1,898/1,684) against the annual testing target. Of those that tested, six percent (120/1,898) were for PrEP refills.

The restarting of community testing from Q4 FY20 along with the fact that the program integrates other clinical services within the other community based HTS resulted in a high testing volume in Q1 FY21. The high testing volume is also a result of the FSW focused organization, VOOV, who had just introduced their Outreach Workers (ORWs) under the KPIF in March 2020 (FY20), right at the start of COVID-19. The ORWs were in the middle of training when it was cancelled due to safety around COVID-19 and the remaining training modules were provided virtually.

When community testing was “un-paused” on August 4th it included mobilization by these additional eight ORWs from VOOV. As new ORWs start, we see a general low case finding as they are learning programming and understanding how to work and identify hotspots. With COVID-19 dynamics and virtual mentoring we have seen that VOOV has still not found their footing in terms of performance. This is important to note as they provide demand creation support for the clinical services for FSWs and MWPS. During the reporting period VOOV demand creation accounted for 26 percent (505/1,898) of those that accessed testing services. Anecdotally we believe there has been a rapid increase in testing linked to COVID-19 as a shift in preference to access health services, not just access to testing, through our comprehensive clinical services.

4 Number of key populations reached with individual and/or small group-level HIV prevention interventions designed for the target population: risk assessment, HIV education, condom and lubricants promotion and provision (CLPP), direct provision/navigation to HIV Testing Service (HTS) 5 Eligible clients: This refers to clients that have not tested for HIV in the last two months and those that have never tested for HIV. Eligible clients are identified by service providers in the clinical service points as we don’t include self-reported data at the community level through the ORWs due to disclosure issues and safety of data at the community level. 6 HIV testing services (HTS) noted in the report under HTS_TST (and HTS_POS as applicable) include HIV rapid test under voluntary counselling and testing (VCT), index testing of contacts identified as well as confirmations for HIV Self testing for those that have screened positive, and for those that have screened negative but want to start PrEP

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It is important to note that such volume was not maintained in Q2 FY21. Due to the COVID-19 second wave the program reduced the number of clients that could access services during outreaches, focusing mainly on HIV care and treatment and prevention services.

Figure 1: Trends in Case Finding Among FSW from FY20 Q1 – FY21 Q2

“pause” in community testing “Un-pause” in community testing

Out of those who tested and got results, 122 tested positive with six percent case finding (122/1,898) but when adjusted for testing connected to PrEP refills the case finding rate is seven percent (122/1,778). This represents 35 percent (122/352) against the annual tested positive target. As show in Figure 1 the program began to see a lower volume and higher case finding during FY21 Q2, as we reduced services as a precaution against COVID-19. During this time, we only promoted HIV care and treatment and prevention services not our more comprehensive services and reduced the number of clients we can support. The modality with the largest volume of clients that access testing is community outreach accounting for 72 percent (1,369/1,898) of total testing and for 70 percent (85/122) of all positives found, while the community center accounts for 23 percent (442/1898) of testing and 26 percent (32/122) of all positives found; appointment based testing (including decentralized drug distribution (DDD), HIVST confirmations and Index Testing) for five percent (87/1,898) and 4 percent (5/122) of all positives found. This distribution was driven by a 7 percent case finding through community centers and 6 percent through community testing and appointment-based testing. The program conducted an Enhanced Peer Outreach Approach (EPOA) campaign among FSW (and MSM) in FY21 Q1. Fifteen seeds were identified, of which 93 percent (14/15) were 30 years and above. From the EPOA data tracked, through the coupon system and linked to the seeds, 32 FSW were tested, with a case finding of 22 percent (7/32). During the EPOA we saw an increase in HIV testing during the first two weeks. Testing went from an average of 91 tests per week in the two weeks prior to the EPOA to an average of

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186 per week in the first 2 weeks of the EPOA. Not all of these are formally linked to the EPOA, as they did not return coupons, but often word of mouth about the EPOA circulates among the networks resulting in increased numbers of people who come to access services but without coupons. Both community outreach and community center testing include clients that want to receive HIVST confirmatory test and Index Testing, as we offer all modalities to ensure that the location or time of testing is not a barrier. The results specific to index testing and HIVST are presented in those specific sections. Improvement strategies: The FSW program is currently over target with HIV testing and under target with positive cases identified. To improve on HTS_TST_POS while reducing over testing, the program is planning to: ▪ Conduct an EPOA, with priority for seeds only 30 years and above who will be tasked to mobilize at-high-risk FSWs age 30 and above and to find seeds in hard to reach sub-population types (strip clubs, mid-to high end hotels etc). ▪ Expand access to new FSW networks, through MWPS to mobilize FSWs. ▪ Recruit peer energizers in priority sub-FSW groups to support mobilization and linking their networks to outreach workers for continuity of support. ▪ Intensify mentoring of ORWs, using both in person and virtual support. ▪ A TA plan will be developed to support the FSW led organization (VOOV) to improve on their performance.

Men having sex with Men (MSM) Reach (KP_PREV)7 A total of 2,752 MSM have been reached with a prevention package of services. This accounts for 87 percent (2,752/3,152) of the annual target. A total of 13 percent (357 /2,752) were known positive, of which 19 accessed community level services such as one-on-one discussions or were given condoms and lubricants but did not access clinical services. 2,733 MSM, or 99 percent of all MSM reached, accessed clinical services, 61 were at non-FHI 360 services. Of those that accessed our clinical services 1,930 accessed testing services, 338 were known positive (included in the 13 percent noted above) and accessed our non-testing services, 9 declined testing and 395, or twenty percent were not due for testing but accessed non-testing services. The program implemented an EPOA in the first quarter of the year, identifying eight seeds, through KPIF partners, to facilitate mobilization and inject new networks to the outreach workers. Impacts relating to COVID-19 are captured under the enhanced development of sustainable prevention programs section that focused on the peer outreach and demand creation aspect of the program. MSM accessing testing services and case finding: The program reached 2,752 MSM and of those 70 percent (1,939/2,752) were eligible for testing and 99 percent or 1,930 tested, while 9 declined testing services. This has accounted for 154 percent (1,930/1,266) against the annual testing target. Of those that tested, 12 percent (225/1,930) were for PrEP refills. Like the FSWs, the MSM also saw a rapid increase

7 Number of key populations reached with individual and/or small group-level HIV prevention interventions designed for the target population: risk assessment, HIV education, condom and lubricants promotion and provision (CLPP), direct provision/navigation to HIV Testing Service (HTS).

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since community testing was “un-paused”, as shown below in Figure 2. While 12 percent of the testing is attributed to PrEP, as noted above, this is still a big increase compared to FY20 Q3. Out of those who tested and got results, 65 tested positive with 3.3 percent case finding (65/1,930) but when adjusted for PrEP refills the case finding rate is 3.8 percent (65/1,705). The absolute number of newly identified positives in Q1 was high, compared to prior quarters, but there was a drop in Q2, which was during the second wave. While the absolute numbers are not cause for concern, the overall case finding has dropped and is a concern as we are over testing. The potential reasons for over testing are noted below. The program is working to address this underperformance, with the improvement strategies noted at the end of this section. The modality with the largest volume of clients that access testing for MSM is through the Community Outreach testing accounting for 97 percent (1,909/1,930) of the total testing, which does include HIV ST confirmations, and 100 percent (65/65) of all positives found, while index testing accounts for one percent (21/1930) of testing and 0 percent (0/65) of all positives founds. As with FSWs the community outreach testing can include clients that want to conduct HIVST confirmations and Index Testing, as we offer all modalities to ensure that the location or time of testing options is not a barrier. The results specific to index testing and HIVST are reviewed in those specific sections. Figure 2: Trends in case finding amongst MSM for FY20 – FY21 Q2

Within the MSM program there have been no programmatic shifts from prior quarters, but we continue to see high volumes of testing and low case finding. Anecdotally it is believed that due to COVID-19 the ORWs have reverted to closer networks, which are easier to reach and to mobilize, and are often under 30 years old and regularly test. Figure 3 below shows a decline in reaching and testing older MSM and increase in reaching younger MSM, below age 30. Testing for MSM below age 30 went from an average of 55.5 percent from previous quarters to 65.5 percent in both FY21 Q1 and Q2. MSM under age 30 consistently have low case finding.

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During the EPOA campaign conducted in FY21 Q1 we reported an increase volume of testing based on word of mouth, but not linked to the coupon distribution that is used to track EPOA specific performance. For example, in the first two weeks of the EPOA we had an average of 202 MSM accessing services, compared to the two weeks prior average of 107 MSM, but only 72 MSM returned coupons during the whole EPOA campaign. The EPOA did not contribute to case finding as only 3 percent (1/32) MSM tested positive from those identified through the coupon-returned system. This low case finding is based on the eight seeds identified by the KPIF partners, with only 50 percent (4/8) being 30 years and above, which is our target age group. As a result, 57 percent (41/72) of those mobilized were below age 30. The selection of “right” seeds is to be corrected in the next EPOA, starting in FY21 Q3. In FY21 Q2 there was a drastic drop in overall testing, but this is attributed to the second wave of COVID- 19 that started at the end of December and went through the end of February. As a result of the second wave, the program reduced the number of services due to restrictions on how many people can access the mobile at a time, as well as curfews that impacted the hours of the mobile and community center. As noted below in Figure 3, there was a slight increase of 7.6 percent in reaching older MSM (30 years and above) in FY21 Q2 from Q1. Figure 3 shows the overall trends for testing by age from FY20 through FY21 Q2. There has been an average of 10 percent (from 52 percent to 62 percent) increase in MSM under the age of 30 accessing testing services from FY20 Q1 – Q3 and FY 20 Q4 – FY21 Q2. Yet the under 30 age group accounted for close to the same HIV testing distribution with 43 percent to 45 percent from FY20 Q1 – Q3 and FY 20 Q4 – FY21 Q2 respectively. The program mobilized and provided testing services to a larger number of MSM under 30, as also explained above, which historically has a much smaller case detection rate, thus impacting performance and supporting an increase in testing but a low case detection rate. Figure 3: Trends in HIV testing distribution by age group amongst MSM

It is worth noting that prior to COVID-19 the program focused on mobilization of MSM that are medium to high risk for HIV, and following the restart of the community-based testing, additional risk factors (e.g.

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GBV, psychosocial needs, willingness to access none-MOH clinical services) were taken into account when assessing for HIV testing eligibility besides risk factors included in the program’s community risk screening tools. This has been discussed with the KPIF partners, but it has been complicated to address in the context of both MSM programming and COVID-19. Under the MSM program, our risk assessment tool results report a high number of medium and high-risk clients being reached whereas their testing results indicate a low case finding. We believe that this is partially linked to the above informal reclassification of who is at risk, but we have also begun the process of reviewing the risk assessment tool to strengthen possible gaps. MSM ORWs will be re-trained to make sure they improve their scoring, and their supervisors will provide more mentorship in terms of how to help navigate those MSM that are at medium to high risk for HIV and need access to testing and prevention methods and those that need other services. In the interim, the KPIF partner’s program managers have been encouraged, and they have started, to do more field supervision to support and correct any errors from ORWs when using the risk assessment tool. Improvement strategies: The MSM program is currently over target with HIV testing while on target with positive cases identified. To maintain achievement on HTS_TST_POS while reducing over testing, the program is planning to: ▪ Conduct an EPOA, with seeds only 30 years and above who will be tasked to mobilize at-high-risk MSM age 30 and above. This is based on data evidence of higher HIV cases among this age group. ▪ Continue to focus on index testing and RNR with fidelity among MSM clients. ▪ Improve strategy of distributing HIVST, focusing on distribution to those high risk for HIV. ▪ Strengthen the targeted testing at the TRUE community centers and mobile sites by targeting only high-risk clients, for HIV, through the risk assessment tools with improved mentoring and supervision by the KPIF partners who manage the ORWs. Transgender (TG) This is the first formal program period for transgender persons under PEPFAR programming. Demand creation for TG is under one of the KPIF partners, House of Our Pride (HOOP). HOOP has engaged two TG outreach workers to help mobilize. During the first reporting period, 68 TG8 have been reached with a prevention package of services. Mobilization for TG women currently includes access to community programming (one on one or access to condoms and lubricants) and clinical services that are KP friendly, but do not include gender affirming care, which is a gap in the program. Gaps in programming are due to lack of funding to support a comprehensive TG program in FY21, and the need for MOH approval. For the TG program, current performance for KP_PREV is at 62 percent (68/110). A total of 45 TG were referred for testing within this period and accessed FHI 360 clinical services, of which 34 TG accessed testing services, or 110 percent (34/31) of our annual target with zero positives identified to date. An additional 23, out of the 68 reached, were either referred for testing, but FHI 360 was not able to provide mobile services to that area, or they accessed services at a MOH clinic, but did not provide an update on the visit.

8 There is currently no size estimate for TG persons in country, but informally mapping of the population through LINKAGES, TransSwati (the TG-led CBO in country) and the recently completed IBBSS and Size Estimation that allowed us to review a subset of the MSM population through inclusion of TG questions, has the population sized between 100-200 TG persons (including both Trans Women and Trans Men).

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The program has also worked with TransSwati, a local TG-led organization, that is not part of the KPIF, to collaborate on TG programming. While HOOP is responsible for demand creation of TG women under the program, collaboration with TransSwati will support a stronger program to support the TG community. HOOP will work closely with TransSwati during the remaining portion of the program to increase demand for services to meet the set targets. TransSwati will also conduct an update of mapping and size estimation for TG community at hotspots/networks level as well as TG 101 discussions, which is about engaging the TG community on issues pertaining their identity, under the KPIF.

Improvement strategies for TG programming: ▪ Conduct training of all HOOP ORWs on transgender issues so they can all support TG mobilization. ▪ Conduct transgender health talks on different topics: psychosocial services (PSS), gender-based violence (GBV), sexual behaviour, prevention, treatment, and care issues related to TG to increase mobilization and visibility of this community through issues of interest to them. ▪ Engage a seed for the planned Q3 EPOA from the TG community. ▪ Conduct weekly feedback sessions with TG ORWs. ▪ Promote the True Eswatini online programs within TransSwati social media platforms as another mobilisation strategy to the TG community.

People who inject drugs (PWID) This is the first formal program period for PWID under PEPFAR programming. 19 PWID received clinical services (6 females and 13 males) 12 percent (19/164) of our annual target; 11 PWID who were eligible were tested for HIV and received their results, 31 percent (11/35) of the annual target; 1 tested positive and was initiated on treatment, 25 percent (1/4) of the annual target.

Under the PWID program FHI 360 collaborates with the Global Fund partner who leads on PWID programming in country, Alliance of Mayors Initiative for Community Action on HIV /AIDS at the Local Level (AMICAALL). We continue to work with them to grow their program, which has struggled under Global Fund, in part due to a lack of a formal harm reduction program which leaves both Global Fund, and PEPFAR, without any specific program to help attract PWID. Thus, the introduction of some basic service provision for PWID as noted above is expected to make a big impact, but also requires a greater stakeholder involvement for the sustainability of the program and future harm reduction initiatives.

Improvement strategies for PWID Programming: The program has started some of the strategies in the reporting period and will be expanding in the next semi-annual period. These include:

▪ Training of service providers: o Short term: Will receive support from the FHI 360 India program to put together a training package and train our service providers on basics of service provision to PWID o Long-term: the program will plan a comprehensive training for providers with the MOH based on feedback from the first training. ▪ IEC material: o The program has received material from the FHI 360 India program and will adapt according to what can work in our context. ▪ Expand mobilization of PWID for service access: o The program engaged a mobilizer for short-term to mobilize PWID specifically.

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o Peer Energizers from PWID will identified and trained. o Conduct EPOA specific for PWID after the EPOA for other populations. Pre-Exposure Prophylaxis PrEP trends among all populations in FY21

As shown in Figures 4-6, 3,770 KPs (1,776 FSWs, 1,865 MSM, 34 TG, 10 PWID and 85 MWPS) tested negative during the reporting period and over 99 percent were offered PrEP, of which 32 percent (1,189/3,644) started on PrEP (544 FSWs, 627 MSM, 8 PWID, 9 TG, 1 MWPS). This is 110 percent (1,189/1,085) of our FY21 PrEP_NEW target for all population types; 79 percent (544/686) for FSWs, 159 percent (627/394) for MSM and 180 percent (9/5) for TG. This also shows a 31 percent (544/1,776) uptake of PrEP services for FSWs; 34 percent (627/1,865) for MSM and 26 percent (9/34) for TG persons, one percent (1/103) for MWPS and 80 percent (8/10) for PWID. Of the 1,189 PrEP_NEW, 80 percent (946/11,89) initiated through the mobile clinic, 19 percent (226/1,189) at the community centers, and 8 through DDD, 2 after HIVST confirmations and 7 during Index. Among the 1,189 KPs new PrEP starts, 57 percent (677/1,189) refilled after 1 month. We also have an additional 601 PrEP refill visits during the reporting period. During the reporting period we have a cumulative 1,461 for PrEP_CURR, over 86 percent (1,461/1,700) of our FY target. Of those that reported to be current on PrEP, 48 stopped PrEP due to various reasons including mild side effects, no longer feeling at risk, unable to find time to go for their re-fills. Some stopped without giving a reason. We also had eight clients restart PrEP. Figure 4: Negative Cascade for FSW – FY21 YTD

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Figure 5: Negative Cascade for MSM – FY21 YTD

Figure 6: Negative Cascade for TG – FY21 YTD

During FY21 the program expanded PrEP refills to be included in our DDD services, of which 43 percent (156/370) PrEP refills were through DDD services. We continue to see strong uptake of PrEP for both MSM and FSWs, and during this quarter among TG as well, but the reasons noted for not taking PrEP remain similar as prior quarters. Clients verbalizing not being at risk, not ready for a daily pill and the need to discuss with partners. We also took the opportunity to address misinformation during the discussions with PrEP clients, whereby some believed that protection would have been reached through one pill only as opposed to taking a daily pill. To improve on the retention on PrEP, for those still at risk the program did the following: • Submitted a concept note to the MOH to roll out PrEP specific bill bottle labels, to reduce the stigma of PrEP not being ART and to provide pill containers for PrEP to allow for more privacy around PrEP usage and to make it easier to carry. These will be rolled out in Q3.

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• Conducted a push on accurate information about PrEP through our HCWs and through our online platforms under the KPIF. • The FHI 360 Linkage Case Manager (LCM) has been working closely with KPIF partner’s LCMs on improving follow up of PrEP clients focusing on counseling support. • The program has also worked to re-distribute PrEP educational videos to be played on the ground at the community centers and at outreaches. Recency Testing Eswatini is implementing surveillance for HIV-1 recent infections: – Eswatini HIV-1 Recent Infection Surveillance (EHRIS) Program. EHRIS implementation began with 39 sites on 1 July 2019 with FHI 360 activation in January 2020 through the implementation organization leading this as research, ICAP, on behalf of the MOH. While still considered research, it is standard of care in all health facilities that have been trained and have the required resources to take DBS or VL. For the semi-annual reporting, 192 tested positive with 83 percent (159/192) of all positives having recency done, including those that are not included in reporting for KPs or PPs. This is 45 percent (159/354) of our annual target. The 33 that were not done (10 in Q1 and 23 in Q2) are due to a gap in training that was addressed in October and in Q2 due to data quality gaps as recency was done but the data was not entered into the recency data base for ICAP, thus their results were not processed at the laboratory. Additional training and weekly checks were instituted once the data gap was discovered in March, as this had not previously been an issue9. The clinical register and daily reporting tools have been revised to capture recency done with providers sharing all used bar codes to the HTS focal person for entry. In Q1, providers (new nurses and counsellors) were trained on the overview of EHRIS protocols, EHRIS procedures in routine HTS, ethics and consent and data collection. The training also included practicals on conducting quality EHRIS procedures.

All providers were provided a refresher training, in Q2 by ICAP, the EHRIS supporting partner. The training focused on mentorship with emphasis on improving data collection.

9 In Q3, during the first week of April, this gap was discussed during an index refresher training. As of that training the HTS officer now checks all tablets to ensure all clients have been entered.

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Linkage and initiation to treatment

Figure 7: Trends in Linkage to ART Among All Populations - FY20 – FY 21 Q2.

The linkage to treatment rate in FY21 is 78 percent (136 TX_NEW and 14 TX_NEW_VERIFY), this is a decrease from FY20 which had a cumulative linkage rate of 102 percent (408/399) as shown above in Figure 7. Post reporting an additional 10 clients have been verified as linked to treatment for a revised linkage to treatment rate of 83 percent (160/192). EpiC Eswatini does not have treatment targets under COP but ensures that our clients have support across the treatment cascade. The program has not reached the 95 percent linkage to treatment benchmark by PEPFAR, as driven by low linkage rate among FSW compared to MSM; but it has continued to improve with more clients directly initiating with FHI 360 and staying within our cohort of services making it easier to verify and track. The program continues to use the MOH’s Linkage Case Management approach, and links clients to ORWs, who are trained on peer navigation. Sixty one percent (118/192) of all HIV positive clients accepted an ORW as a peer navigator. The main reason why clients do not want to link with an ORW is due to privacy reasons, but they are linked to the Linkage Case Manager (LCM) from FHI 360, or from one of the KPIF partners, who have an LCM. Twenty-nine percent of HIV positive clients (56/192) did not initiate on the same day, and of those 51 percent (30/56) have since initiated. All clients that did not initiate on the same day or are still pending initiation are being followed up and supported through counselling by the ORW, if linked, and by the LCM until they overcome the barriers of enrolling into treatment. There are also 9 clients that we are not able to locate due to incorrect contact information. While we try to verify all contact information on site, clients will claim they do not have their phone with them or will say they are borrowing the phone to call a family member instead, and then subsequently give a false number. We continue to experience delays in verification, for clients that choose to initiate at MOH clinics, due to COVID-19, as clinic visits to verify ART registers have not been safe, and verification over the phone has mixed results as HCWs at the clinics are overburdened. The program continues to work with clinical partners and use the MOH’s electronic medical record system (CMIS) to verify but often see a gap in data entered. The MOH has noted there are delays in data entry for “down time forms” so data from the CMIS is not always up to date, with months back log at some clinics. We also continue to also see difficulty based on demographic information not matching information in the CMIS.

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The issues relating to verification of clients at MOH clinics will be addressed in Q3 as the program moves towards an integrated data collection platform for our clinical data, directly linking with the MOH’s CMIS. This will allow the program to directly verify clients access at MOH clinics, and it allows us to register the client directly in CMIS during service provision, thus when they go to the clinic the demographic information will match. We are also in discussion with the MOH about requiring clients to have their national IDs when accessing services to ensure verification. This is currently not a requirement for the MOH, but we continue to see discrepancies, as does the MOH, where clients will initially present under one name for testing but will then return to initiate or refill under a different name, with their national ID. This on its own is not abnormal to our program but it is further complicated as we are not within the larger MOH system until we move to the CMIS projected to be in FY 21 Q3. Linkage and initiation to treatment for FSW: In Q1-Q2, 83 FSWs were directly initiated to ART by EpiC, and 15 were confirmed to have linked to treatment with their preferred clinic, resulting in 80 percent (98/122) of clients confirmed on treatment10 as shown in Figure 8 below. Delays in verification of clients initiating at MOH clinics is discussed above. The FHI 360 LCM provides support for all FSWs, as during the KPIF program VOOV does not have an LCM on staff. To address the low linkage to treatment rates EpiC Eswatini will implement the following strategies: a. Review schedule for the community center and home-based appointments/DDD, which supports initiations, to ensure that times/days work for the FSWs. b. As the MSM LCMs continue to grow, shift focus to FSWs to intensify support. c. Work with health care workers to ensure that counselling and support during services is strong and guide on counselling areas for those that “want to think about it”, “want to consultant their partner” or “those that are just not ready”. Figure 8: Positive Cascade for FSWs – FY21 Year to Date

10 Clients are tracked in two categories: treatment initiation through direct service delivery (TX_NEW) and those that we can directly verify at the clinic where they access their services and are supported through the program through appointment reminders, counselling as required, peer navigation support at the community level (TX_NEW_VERIFY).

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Linkage and initiation to treatment for MSM: In Q1-Q2, 50 MSM were directly initiated to ART by EpiC, and 15 were confirmed to have linked to treatment with their preferred clinic resulting in 100 percent (65/65) of clients confirmed on treatment as shown in Figure 9 below. The LCM’s under the KPIF partners have been working hard to ensure that all MSM that do not initiate on the same day are linked to the MOH clinic or are provided with home-based initiations. Figure 9: Positive Cascade for MSM – FY21 Year to Date

Continuation on treatment11 During the reporting period, a total of 296 clients were due for ART refills, and of those 86 percent (255/296) received their ART refills, 16 percent (40/255) refilled through DDD, as shown in Figure 10, 13 percent (32/255) through community mobile outreach and 72 percent (183/255) through the two community centers. For the 14 percent (41/296) who interrupted treatment, 12 percent (5/12) were refilled and returned to treatment. Of the 36 that have interrupted treatment, 10 are part of the FHI 360 cohort (receiving treatment through FHI 360) and 26 were receiving treatment at MOH clinics. 27 of the 36 were not reachable as they have changed numbers or have moved and did not inform our team to where they have moved.

Permanent site refills12 identified in FY20 Q4 failed to take off with few ART clients preferring refills at the community centers or nearest facilities. This has been reviewed with the need to go to areas that need services or that are further away from the public health facilities. Further development of this activity was suspended due to the 2nd wave of COVID-19, and focus moved to home based DDD to scale up for ART refills, as well as PrEP refills.

11 The program supports ART refills through the following methods: Community Centers, which are KP focused drop-in centers; DDD which is normally home-based appointments for refills for clients devolved from our own community centers or from MOH clinics and through Mobile Outreach which is our routine clinical services, which includes initiations and refills for locations we routinely frequent. 12 Permanent site refills are “hotspots” where FHI 360 will return monthly with our mobile, allowing for refills for ART, and PrEP.

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Figure 10: ART refills for FY 21 year to date, with the breakdown for DDD refills ART Refills 70 59 60 47 50 39 39 39 40 32 30 20 19 10 3 11 7 0 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Total Refills DDD Refills

Figure 11: TX_NEW and TX_CURR services for FSWs for FY21 Q1-Q2

For FY21 Q1-Q2, 152 FSWs have reported to be current on ART, with ten of those clients having been returned to treatment, as shown above in Figure 11. This overall provides a loss of 59 clients from our last reporting period (FY20 Q4). This loss is based on TX_CURR_VERIFY being impacted by COVID-19, as noted above. The impacts for FSWs are greater as often FSWs use different names when accessing services and requires addition verifications to ensure it is the same person, and there are more clinics that FSWs prefer compared to MSM, just based on overall larger numbers of FSWs. If we are not able to verify that they went to their visit, when scheduled, we are not able to report them as TX_CURR_VERIFY. This does not mean they did or did not honor their appointments it means we are not able to verify. While we call clients, we often find self-reporting does not match what is found at clinics. We hope that with the adjustments noted above and with the introduction of CMIS into our data system we are better able to

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capture this in real time, and thus provided adjusted support to clients that are truly interrupted in treatment. Figure 12: TX_NEW and TX_CURR services for MSM for FY21 Q1-Q2

For FY21 Q1-Q2, 154 MSM have reported to be current on ART, with three of those clients having been returned to treatment. This overall provides a net gain of 24 clients from our last reporting period (FY20 Q4). This gain is based on the follow up done by the KPIF Partner’s LCMs with guidance from the FHI 360 LCM officer and through support through the ORWs, for those linked. 255 clients received 3 MMD (Multiple month distribution) out of 289, or 88 percent, but there is a need to increase to 6 MMD after getting clients VL results, with suppressed results. The 34 that did not receive 3 MMD but received less is due to supply issues around expiration dates, and the clients not being eligible for 3 months. 100 percent of clients are provided with TLD (TDF,3TC, DTG) treatment regimen.

Documentation of Viral Load Testing Suppression FHI 360 coordinated with AHF to start the process of taking VL for the clients accessing services from FHI 360. Taking VL from clients at FHI 360 services started in January 2021. Current VL report captures clients from the FHI 360 cohort and MOH cohort, as we only started conduct VL directly in Q2. As we conduct VL testing in future quarters we will break out the reporting accordingly. As of Q2, 112 clients were eligible for VL, of which 53 have been taken and 31 have received results. Of the 31 results received, 29 are suppressed and two unsuppressed, providing a viral load suppression rate of 94 percent (29/31) with 22 are awaiting results. VL Clients are mainly reached through DDD and community center services. The two unsuppressed are undergoing Stepped Up Adherence counselling13. The status for the two unsuppressed clients is that one has been redrawn, post the reporting period,

13 Stepped up adherence counselling (SUAC) is a MOH approved counselling tailored for clients with poor adherence or unsuppressed VL. It is found in the 2018 HIV care guidelines. A client with unsuppressed VL is called and informed of the result. Client is refilled monthly and follow up done by LCM with assistance from the ORWs linked.

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and now suppressed and the second has been booked for viral redrawn and has been provided counselling support. FHI 360 collects blood samples, through whole blood and spin, and submit to AIDS Health Care Foundation (AHF), our mother facility, that then submits to the National Lab. There are currently gaps in getting test results returned as the national ID (or a secondary option is a phone number) is used to track the lab samples and results are directly returned in to the MOH electronic medical records (EMR), the CMIS. For most of our clients we do not require, but do request, a national ID to initiate or to obtain refills. This is becoming a gap within the submission of the VL data, which we will work to address with the MOH. The program has not started VL DBS blood draws pending SOP approval from the MOH. When approved, EpiC will be able to send DBS samples directly to the National Lab without the need to spin as dried samples can be kept for two weeks. The TX_PLVS_VERIFY reporting still has gaps in terms of providing a comprehensive view of TX_PVLS/TX_PVLS_VERIFY for KPs but the ability to report this data shows an increase in improved success accessing VL results due to access of results at the clinic level, which was not the case at the start of the FY. During the current reporting period there is no VL data related to MWPS and PWID as they are not yet eligible. Commodity distribution: The program distributed 601,106 male condoms; 91,630 female condoms and 415,294 lubricants to KPs during clinical services and through the community outreach workers. 58 percent of all distribution is through outreach workers at the community level. Index testing Figure 13: Index testing cascade for all populations, FY21 Semi-annual report

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Index testing was offered to 291 (186 FSWs, 94 MSM, 1 MWPS, 1 PWID and 2 non-KP) with 191 being newly tested clients and 100 known positive clients. Of those offered, 84 percent (244/291) accepted index testing and provided 349 contacts or a 1:1.43 ratio as noted in Figure 13. EpiC Eswatini does not have COP targets linked to index testing but we implement it as it is standard of care under the MOH. The following results are as of the time of submission of this report, or as of April 20, 2021, while the graph above depicts the results as of the time of reporting in DATIM. Out of the 349 contacts that had been elicited, 137 (43 percent) were found and either tested or reported as known positive. Of the 137, 63 percent (86/137) were known positive and 51 were tested and two tested positive (4 percent case finding). Among the 212, not reached, 53 were un-reachable through the numbers provided, 17 continue to not answer our calls, and we are not able to find them in person, 18 declined testing, 87 are pending contact and 37 have been reached but not yet tested during the reporting period. Thus only 295 clients (elicited contacts minus those unreachable) were viable contacts. Of the 37 pending visits, two continue to not pick up the phones when confirming their appointments,4 phones have been off since we originally set an appointment with the client, two have tested positive (and will be reported in Q3), six were negative (and will be reported in Q3), three are known positive, one declined, 19 continue to reschedule their appointments. The two that tested positive, during the reporting period, requested to initiate at a facility of choice and are being contacted to confirm if linked on treatment and two clients were initiated on PrEP.

In Q2 the program offered virtual indexing, reported in the above, to four clients who had been identified in a review of our index tracker as not having contacts elicited during routine services and three accepted and six contacts were elicited for a ratio of 1:2. Of those contacts we have reached 16 percent (1/6) with one testing, with a positive result. The program continues to utilize virtual indexing if any clients are missed during clinical services. Figure 14: Index testing cascade for FSW and MSM, FY21 Semi-annual

The population specific index cascades, as shown in Figures 14, look similar with consistent gaps that need to be addressed. We also conduct index testing for PWID and MWPS (and will for TG when eligible) but currently the numbers are too small to determine any population specific needs for PWID and MWPS. The main gaps are discussed in the Table 1: Eswatini TA on Index Testing Action Plans. The program has a low rate of finding elicited contacts, per Figure 13. We are at less than 50 percent for both males and females. Historically the program had partnered with PSI and TLC to help conduct tracing for hard-to-find clients, if not found after 14 days, due to their ability to canvas a neighborhood to enable

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them to test the targeted index client. In 2019 PEPFAR changed how Clinical and Community partners were asked to collaborate around index testing interrupting this approach. EpiC Eswatini will reach out and see if we can re-establish this collaboration. Starting at the end of the reporting period we began trying to verify contact information for the contacts elicited through the main mobile carrier in country, MTN to see if their numbers are registered and confirm the names. This will help in ensuring we have accurate phone numbers as the starting point. Index testing is offered through our community centers, community outreach and available through appointment/home-based testing services. During the counselling we work with the client to identify what is the best service option to ensure we do not disclose the index clients KP status. Overall index testing is primarily done through booking contacts for home-based testing and followed up by a nurse who offers testing services and offers ART to positive clients and PrEP to the negative clients. Index testing while a targeted activity with two dedicated days weekly continues to require extensive focus due to the number of contacts we can test daily through appointment-based testing. While we organize by geography, we are only able to support three to five contacts per day, as most choose appointment-based services versus accessing our mobile outreach or the community centers, and often contacts reschedule last minute or do not show up for the appointment. For efficiency we combine index testing with HIV ST confirmations, and DDD services which are also done through appointment-based services. Three EpiC Eswatini staff were trained on Intimate Partner Violence (IPV) and index testing, as trainer or trainers, with training materials that speak to the needs of our populations. The team then cascaded the training to the eight additional HCWs that support EpiC Eswatini clinical services. An additional training is planned for April to train any new HCWs, as well as to provide a refresher on Index Testing. During this reporting period an SOP IPV for Index Testing (and HIV ST and PrEP) was completed and approved. The Eswatini team engaged support from the EpiC technical assistance team. We reviewed current data, identified where we need to improve programming, and identified approaches to support improving our performance under index testing, captured in Table 1. Table 1: Eswatini TA on Index Testing Action Plan Issue Actions to Consider Status Observe providers when providing ▪ All HCWs were observed when providing index testing. Feedback was Improving index testing and assist them where provided to all HCWs. The main gaps identified were: contact there are gaps. A. Not providing index testing to those that are known positive or not eliciting documented for viral load, or in some cases not offering indexing. B. Index testing being offered posttest when program guidance is to index prior to testing. C. Not asking about other sexual partners or associates besides the stable partner Consider a mystery client approach ▪ We received feedback from pre-identified clients on their indexing who can give a feedback on where to experience. The main feedback provided was: strengthen support. A. Known positive clients were not asked their viral load B. Associates and children not asked during index testing. The program is not able to conduct testing services on children, and thus all those indexed will have to be referred to a regional clinical partner. C. If partner is on ART, the client was not asked when ART was started and if the viral load was taken. ▪ The program will conduct a more formal mystery client approach in Q3. Training of providers should also ▪ Inclusion of complex case studies was included in the index refresher discuss complex case studies and how course held in Q3, on April 7th-9th to deal with them. Review current index testing script ▪ Current scrips were reviewed, but it was determined that these were and make it stronger. sufficient.

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Issue Actions to Consider Status Eliciting from clients who have HIV+ ▪ This is being reviewed by our clinical team to help to document this partners under indexing. Tracking TX_CURR and ▪ Program has re-discussed with HCWs that all HIV + clients that are not TX_CURR_VERIFY cohorts: yet suppressed, are not yet on treatment or have only recently become suppressed, are indexed. Anyone that might be identified as missed, post service provision, is virtually indexed. Eliciting RNR from clients: ▪ The program utilizes peer energizers (to support access to risk This will require adding narrative of networks) and we implement an EPOA. In addition, we are integrating RNR in the eliciting script and RNR into our index approach including documentation in the index recording separately in the tools. reporting documents and updating the script. The indexing script to include RNR needs to be completed with our KPIF partners to ensure we are sensitive to the populations. We expect this to occur in Q3.

HIVST Figure 15: HIV Self Testing Cascade all populations, FY21 Semi-annual

Figure 16: Trends in HIV Self Testing Among all Populations – FY21 Semi-annual

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2,077 KP and priority populations (PP) received (were distributed to) HIVST kits (1,477 FSWs, 366 MSM, 21 PWID, 111 MWPS, 26 TG and 76 were uncategorized), this is 23 percent (2,077/8,904) of our annual target. The current quarterly allocation from CMS, of 1,750 per quarter, will not allow us to reach our annual target. In addition, we only received our allocation for Q2 at the beginning of March but had started to run out in December. Of those distributed 96 percent (1,997/2,077) were through assisted and 80 unassisted distribution. Program beneficiaries primarily choose assisted at the community level to allow support on completing the HIVST screening and providing ability to access an appropriate referral to necessary care and quick access to confirmations for those that have screened reactive or want to start PrEP. As shown in Figure 15, 91 percent (1,888/2,077) were reported used and of those 4.7 percent (88/1,888) were reported as screened reactive, 71 FSWs, 10 MSM, 6 MWPS, and 1 TG. Seventy-nine, or 90 percent (79/88) were provided testing for confirmation by the program and 8 were confirmed at a facility of choice. Of the 79, 47 (32 FSWs, 9 MSM and 6 other) were confirmed positive, or a 2.4 percent case finding, 0 were known positive and 32 were confirmed negative and of the eight confirmed at facility of choice no results were provided. One percent (1/88) were pending confirmation of results at the end of March, not including the eight that have refused to provide their results. For those pending confirmation they are attributed to ORWs who resigned, and we can no longer trace their contacts, and to clients not scheduling for confirmations to be completed or confirming at another clinic but not providing us the information. As of April 30, 2021, of the 1,888 that were reported as used, 116, or 6.1 percent, screened reactive, with 81 confirmed as reactive, for a 4.2 percent (81/1,888) and 94 percent (76/81) were confirmed linked to treatment. As a program we continued with the process of strengthening demand creation for and distribution of HIV ST kits at the community level. This reporting period, distribution of HIV ST was focusing on clients who are at medium and high-risk, according to the risk assessments thus not to anyone that wants a kit. This was a shift from previous implementation experience. In addition, the ORWs used the risk network referral (RNR) method. After the Outreach Worker has assigned a risk score to a peer, that is high or medium, the peer is given HIV ST kits to give to their networks and follow up is made on the used HIVST kit.

Community distributions of HIVST kits continued in Q1 and the beginning of Q2 to allow KPs to have access but was not active in hotspots like bars, hotels, and clubs because they were closed. These community distributions have since been reduced as the lockdown restrictions were lifted and ORW were able to move and conduct one on one distributions. There was a challenge with community distributions as the ORW were not able to track the use of these kits and follow ups were difficult due to incorrect contacts left at the distribution point.

HIVST contributes to 24 percent (47/192) of all cases identified through the main testing modalities, but currently we have a 2.4 percent case finding rate, but as noted in Figure 16, both December and February having high percentage reactive rates, 16.7 percent, and 8.3 percent respectively. There were no new approaches or interventions used during that time so we plan to further look at disaggregation of the HIVST data to help guide where we can improve distribution to see if that is the reason for this shift. We do think it is based on some KP partners being stronger at identification of medium to high-risk individual and when they distribute during the program period. As the current HIVST case finding by KPIF partner and FHI 360 are:

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• FHI 360: 4 percent (73/1625) • VOOV: 0 percent (0/415) • HOOP: 1 percent (2/248) • HP4M: 1 percent (6/520) • AMICAAL (Global Fund Sub Recipient): 0 percent (0/137) Looking at the individual performance of the CBOs helps to guide where to focus mentoring for improved targeting, we will further cascade this by KPIF partner and ORWs. FHI 360 is working with VOOV to help better target their HIVST kits including working with their ORWs directly to mentor and guide, as well as having them learn from the regional ORWs. Data challenges continued to persist during the reporting period. Clients were referred to the mobile outreach or to the community centers for HIVST confirmations, but upon arrival they would present for testing services and not mention HIVST confirmations. The program has decentralized community HIVST registers to ORWs and developed a SOP for data management specific to HIVST, to improve data collection and reporting. The program has also strengthened communication between the Clinical department and Outreach to allow timely booking and reaching of clients that are due for confirmation, as shared by outreach workers after receiving results from their peers. TB services: The program screens clients using the standard approved MOH tool. A total of 6,980 clients (4,199 FSW, 2,603 MSM, 38 TG, 18 MWPS, 19 PWID, 45 TOPs and 58 other populations) have been screened for TB. Ten clients (8 FSWs, 2 MSM) screened positive (presumptive cases) and 1 did a diagnostic test (GeneXpert, sputum smear microscopy, X-ray, TB LAM or other) and we are pending an update on the result. STI services: Screened (through syndromic screening) 6,312 KPs (3,838 FSW, 2,419 MSM, 40 TG, and 15 PWID), 64 MWPS and 43 other population. Of the screened clients, seven percent (440/6,419) were diagnosed and 95 percent (418/440) were treated for STIs. Anyone not treated for STIs was due to requiring a visit to the health clinic or due to a lack of medicines. Common symptoms diagnosed and treated were vaginal discharge and lower abdominal pains among FSWs and male urethral discharge among MSM. These syndromes continue to be dominant since the beginning of the program. VIA services for FSW: Due to COVID-19 EpiC has not re-started VIA services. Clients requesting cervical cancer screening services are referred to the nearest health facilities providing VIA services. Psychosocial care: Provided 69 KPs psychosocial support through virtual counselling under EpiC programming. As of this quarter, a cumulative 66 percent (226/344) of clients who were supported, since the start of FY20, for psychosocial care have had their cases closed, while 80 were lost to follow-up and 38 are still receiving on-going support. PSS services were transitioned to the KPIF program in Q2. Prior to the transition a handover meeting occurred, and support continues to be provided, as needed.

Enhanced development of sustainable prevention programs COVID-19 continued to impact program implementation for key populations. During the reporting period we saw a relaxation of travel restrictions and curfews, opening of restaurants and bars, restrictions on the number of attendees at community events and sales of alcohol lifted. We also saw, beginning mid- December a stark increase in new COVID-19 cases that began the second wave which lasted till the end

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of February. During the second wave the country went back to a restricted COVID-19 operating environment and extended restrictions to include the closing of church and a ban on all meetings that were more than twenty people and for front line workers. A number of these restrictions were lifted in March 2021 and schools re-opened on March 29, 2021, the first time in over one year. All of this has impacted our KP programs. Each population has had their own dynamic change, shift, and adjustment. Key population members are still working to adapt to these changes within their own populations, considering the impacts of COVID-19 on the community’s life, as well as the organizations that support them. In Eswatini a number of these impacts are felt greater because of the small size of our country, where family is interlinked, mobility is big but without funds there are only few places to access support and where there are still few services available to address the impacts of COVID-19. Overall, this impacted our prevention programs as it continually changed how we program. The below outlines the progress during the reporting period. Risk segmentation and tailored services • Conducted both virtual and paper-based risk assessments, referring clients for services based on need based on the risk score and the discussion with the client. The virtual risk assessment, through TrueEswatini.com was mostly done by the OW on behalf of the clients. Clients who had access to internet were also able to do their own risk assessment and continue to book for services as suggested. • An advantage of the client conducting their own risk assessment is that they have confidentiality, and it minimizes the element of not telling the truth, by answering what they believe the ORW wants to hear, hence more legitimate information. • For results, please see detailed outlined section 2 under Attain and maintain HIV epidemic control among key populations (KP).

Demand creation for HIV prevention services and peer outreach Demand creation efforts continued regardless of COVID-19. As a continuation from the last quarter of FY20, the outreach team: • Adapted a blended approach in demand creation. The approach mixed the use of virtual services and face to face interactions and was adapted based on government restrictions. During October and November and at the end of March, with the ease of the lockdown, the team managed to conduct home visits for one-on-one sessions and small groups of not more than five people at a time. • A reduced package of services was offered, virtually, including HIVST, condoms, lubricants, relevant IEC materials for COVID-19, access to virtual PSS services, and for a reduced number access to HIV testing services (HTS), STI screening and treatment and TB screening. Outside of the catchment areas for the two active TRUE Community Centers (Mbabane and Manzini), which maintained clinical services, the services provided included tele-navigation support, access to HIVST kits, condoms, lubricants, information relating to COVID-19 and HIV prevention, and virtual small to medium group sessions or one-on-one discussions. • Access to hotspots was also reduced as bars, casinos, shebeens (informal drinking spots) remained closed at the time of reporting and was closed for close to three months during the reporting period. • Reaching FSWs through virtual platforms continues to be challenging as not all FSWs have access to mobile phones and some stay in remote areas where the network is also a problem.

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• Conducted a total of 187 outreach mobile clinics in selected urban, semi-urban, and rural communities and 136 community center services. • Strengthened mentorship sessions with all 26 FHI 360 ORWs as well as ORWs from the KPIF partners, to assess and identify gaps in activity implementation in their allocated geographic locations and hotspots. Typically, mentorship sessions are enhanced by virtual weekly meetings where plans for gaps identified are presented and implemented by EpiC and the KPIF partners. • Implemented an EPOA from mid-November until mid-December. Through EPOA the outreach team supported the reach of 1,494 clients with clinical services (1,245 FSW, 146 MSM, 27 TG, 4 PWID, 69 MWPS and 3 uncategorized) through mobilisation and administering of HIVST kits and HIV prevention commodities. • Conducted virtual weekly reports with Regional ORWs to provide technical support and supervision and progress. • Social media platforms, such as WhatsApp, Facebook, Twitter, and Instagram, were leveraged for demand creation, including service hours and appointment bookings. • Demand creation for psychosocial services (PSS) continued and clients were supported for PSS virtually, with counsellor providing services over the phone during the first quarter of the FY (October – December 2020) through FHI 360, and then subsequently through HealthPlus 4 Men. ORWs assisted clients to make booking for the services through Online Reservation Application (ORA)14. o Strengthening of index testing which included both virtual and in person contact eliciting. o Continued implementation of unique strategies developed in FY20, Q4 to improve service uptake were developed under limited programming, including contact elicitation for risk networks and more online approaches.

3. Improve program management (including health information systems [HIS] and human resources for health [HRH]) and financial systems to ensure attainment and maintenance of epidemic control

• Provided human resource (HR) support for three staff positions at the MOH Lavumisa Wellness Clinic, funded by PEPFAR, through March 2021. The clinic provides services to KP members, including transport operators, but they are not specifically reaching those that are medium to high risk. Support to the Lavumisa Wellness Clinic was planned to be short- term (less than one year) and had started in 2019. • Supported the MOH regarding the KP Database, with support from USAID, to integrate the data system into the national level electronic medical record (EMR) known locally as the Client Management Information System (CMIS). This support, through the MOH, includes: o Development of KP relevant dashboards. o Adaptation of current program clinical tools to compliment the CMIS. o Adaptation of certain data tools to better fit the larger CMIS system, specifically, PSS services, as well as the integration of the risk assessment. o Identification of data points to be transitioned from FHI 360 to the KP database, once finalized.

14 ORA is the application to support online appointment booking that is done via the TrueEswatini.com site.

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o Began data entry of other 30,000 data points through support under the EpiC HBF program. o Through TA from FHI 360/HQ, and in coordination with the KPIF partners, developed a community module in the DHSI II tracker. This module will provide relief to the KP program, that is very heavy on paper-based tools, as an interim solution until it is integrated into the MOH CMIS.

4. Support the transition of prime funding and implementation to capable local partners to meet the PEPFAR goal of 70% of funding to local partners by 2020

• Technical capacity strengthening for KP led CBOs were conducted. • Developed partners’ meetings plan to support improved programming. This plan was developed by FHI 360 and CANGO, including: o Weekly individual CBOs performance technical review meetings. Discussions regarding operations and administrative issues were also included. o Bi-weekly combined CBOs performance technical review meetings, including learning and support across CBOs. o Monthly meetings for all CBOs and other partners to review performance of clinical and non-clinical services in the two KP Community Centers. These are led by the organizations managing the coordination of the community centers (HOOP and HP4M). o Monthly learning sessions (deep-dive discussion) on selected technical thematic areas in the program. o Monthly meetings between CANGO and FHI 360 to review performance of the program overall. Almost all these meetings were held in the reporting period, except the monthly meetings for CBOs to discuss activities in the community centers. Highlights from some of the meetings include discussions on: EpiC’s menu of technical strategies to address key gaps for epidemic control and service delivery continuation, writing a success story, implementing a successful EPOA and structural interventions. • Transitioning of programs to CBOs: o PSS services from FHI 360 to one of the CBOs, HP4M, who started implementing this activity in January 2021. o Began the process of transitioning FSWs ORWs from FHI 360 to VOOV, the FSW-led CBO. VOOV was about to finalize the process of engaging the ORWs by the end of the reporting period with call for applications and interviewing. • Support to one KPIF partner towards improving transgender programming. • Provided support to CANGO to formalize a strategy for capacity development monitoring and tracking system for the KPIF partners to help better document the path to graduation to transition awards under USAID. These were presented to all four partners under the KPIF, with only one, HP4M, providing feedback. • Strengthened ORA through training of program service providers to make sure all clients provided service who booked from ORA have their results completed in the system to complete the reporting cascade. This has improved as nurses are recording clients’ facility visits outcomes in ORA. • Strengthen National Level Monitoring and Evaluation Systems programming for NERCHA can be found in Section II of this report.

EpiC Eswatini Semi-Annual Report (FY21 Q1-Q2 October 2020 to March 2021) 26

Gender: • Please see section on PSS services.

Policy and Advocacy: • Conducted a roundtable meeting on TG programming with MOH leadership and stakeholders, including USAID, local key government departments, non-governmental institutions, and community-based organizations on how best programming for TG can be improved in the country. From the meeting it was agreed there is a need to expand TG programming in-country to include gender affirming services. • The round-table meeting was followed by other strategizing meetings with the MOH where it was agreed that a strategic plan for transgender programming was needed in the long term while expanding current programming for transgender through TransSwati and under EpiC, within the current menu of services available15. • TransSwati was also engaged to discuss activities to be implemented to support expanding the TG programming. CANGO started working with TransSwati to develop a list of activities to be implemented by TransSwati in the current FY. SZL 160,000 (US 10,000) has been allocated to support these activities. • Two ORWs have been engaged, under HOOP, to support TG programming.

PWID Programming: • Supported and completed a “drugs stock-taking” activity which was an assessment to map and identify issues on people who use and inject drugs in the country. This was through Global Health Initiative and MOH with TA from FHI 360. Results from the assessments were shared with size estimates and hotspots for people who use/inject drugs. • Collaborated with seasoned PWID program and received materials for developing Information Education and Communication (IEC) and/or training material. • Developing, with MOH, short- and long-term plans for expanding (from work currently being done under GF) on PWID specific programming. • Event-driven PrEP: Worked with the MOH PrEP focal person to present on Event Driven PrEP to the PrEP Core Team. During the meeting we received approval to roll out Event Driven PrEP in Eswatini. Will work in the next reporting period on development of a standard operating procedure and to update the existing clinical guidance on PrEP. • KP partners providing clinical service: received approval to support the KP partners to directly provide clinical services, in additional to HTS services, to their clients at the KP TRUE Community Centers. The only requirement is that they engage nurses that are qualified and registered to provide the services. This will start in FY22 based on no funding being available to support this activity under the KP partners in FY21.

C. Management and Operations Program Management • Completed the FY21 EpiC Eswatini workplan, for submission and approval from USAID. • Developed and submitted a Workplan for Adjustments to Mitigate COVID-19

15 The current menu of services for KPs is comprehensive but does not include gender affirming healthcare services. It provides KP-friendly services in locations and times that are more accessible for TG women.

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• LINKAGES Eswatini successfully transitioned to EpiC. • Three new staff joined EpiC Eswatini including a new Finance Manager, M&E Lead, and a Senior M&E Officer. • EpiC Eswatini continued to provide constant updates to the program team and KP partners under the KPIF on the COVID-19 response and guidance shared to address implementation within programs, including: o Supported and contributed to multiple updates at both the organizational and the client level in relation to COVID-19. o Conducted weekly staff check-ins that provided updates about COVID-19 in country and provided an opportunity to refresh staff with information regarding infection prevention control (IPC). o Presented to all staff information on GBV and COVID-19 impacts. Sessions included how to access psychosocial services during COVID-19. o Supported staff and HCWs towards ensuring that they register for COVID-19 vaccination. o Routine review of FHI 360 Eswatini office operating status during the COVID-19 era and providing support to staff working remotely. • EpiC participated in-depth key thematic areas discussions with HQ technical advisor’s support and reviewing data program performance. • Provided Expression of Interest for KP-Led organizations receiving KPIF and supported with review of expression of interest. • Collaboration with clinical partners: Met with EGPAF and Georgetown University to develop/update MOUs, including sharing of clinical data for improved access to clinical data from HC facilities. The MOU with EGPAF was finalized and signed as well as M&E SOP and collaboration standards within the VMMC program, discussions with Georgetown University are still on-going. D. Human Subjects Protection • N/A

E. Environmental Compliance • Submitted the Environmental Mitigation and Monitoring Plans (EMMPs) to USAID for FY21 to USAID/Eswatini on March 17, 2021 • Submitted an Environmental Review Form to USAID/Eswatini on March 17, 2021

F. Success Stories, Visuals and Best Practices • Please see Annex F for the following success story: “Our lives have been saved”: How Community-level KP Support on Treatment Continuity has Saved Lives.

G. Media Coverage, Tools and Publications • Collaborating under the KPIF program to develop a standard operating procedure for “Using Mobile Devices and Apps for Virtual Client Support Eswatini.

H. Priority Activities in the Next Six Months (April to September 2021) During the next six months in Eswatini EpiC will: • Conduct an EPOA for FSWs, MSM and TG. • Support a COVID-19 vaccination site for the KP partners to access the COVID-19 vaccine.

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• Improve performance for FSW targets through supporting VOOV in developing, implementing, and monitoring strategies. • Expand PWID programming: training of service providers; engaging mobilizers; conduct EPOA for PWID; develop IEC material and engaging MOH on strategic framework. • Roll out PrEP bottle labeling and PrEP containers. • Support roll-out of event-driven PrEP: engage MOH and support activities as suggested by the ministry. • Complete process of transitioning FSW ORWs, that meet a minimum standard of performance from FHI 360 to VOOV. • Complete review and modify risk assessment tools. • Develop Poster for the abstract that was accepted for the IAS conference. • Develop and share with MOH a TG strategic plan. • Continue technical capacity of CBOs, adding support from HQ TA backstops. • Conduct TA sessions with program staff on identified thematic areas. • Train short-term staff: will train our service providers, and other locum-staff on operational and program technical issues during low COVID-19 testing. • Participate in the development of the PrEP Communication Strategy including providing conducting HCW and Client interview guides. • Support and monitor Community Engagement grants. • Develop workplan for FY22. • Begin planning and roll out Gender Affirming care for TG within the EpiC KP Community Centers. • Roll out of DHIS II tracker.

EpiC Eswatini Semi-Annual Report (FY21 Q1-Q2 October 2020 to March 2021) 29

Annex A: Performance Monitoring and Evaluation Matrix

Positive HTC services for HIV and received DSD 352 35% 65 114 57% 0 2 0% 1 4 122 25% their test results HTS_SELF: number of self-test kits DSD 4374 40% 964 4028 24% 29 296 10% 21 280 7.5% distributed 1732 HTS_SELF_USED: number of self-test kits DSD - - 903 - - 29 - - 21 280 7.5% used 1645 PrEP_SCREEN: Number of individuals who DSD 1030 171% 1865 589 316% 20 7 443% 10 31 have been screened for eligibility for PrEP 1767 32% PrEP_ELIGIBLE: Number of individuals who

are eligible for PrEP during the reporting DSD N/A N/A 1862 N/A N/A 10 N/A N/A 8 0 N/A 1757 period PrEP_NEW: Number of individuals who have been newly enrolled on PrEP to DSD 686 79% 627 394 159% 9 5 180% 8 0 prevent HIV infection in the reporting 544 N/A period PrEP_NEW_VERIFY: Number of KPs who were successfully referred for PREP with DSD - - 0 - - 0 - - 0 0 confirmed PrEP initiation during the 0 0 reporting period. PrEP_CURR: Total number of individuals,

inclusive of those newly enrolled, that DSD 1051 62% 785 642 122% 14 7 200% 8 0 652 received oral antiretroviral pre-exposure N/A

EpiC Eswatini Semi-Annual Report (FY21 Q1-Q2 October 2020 to March 2021) 30

Achievements/Targets for our core target populations Female sex workers MSM TG PWID PEPFAR % FY21 % FY21 Year Annual % FY21 % FY21 Indicators support Year Year Year Annual target Annual target to Target target Annual target Type to to to Target achieved Target achieved Date achieved Target achieved Date Date Date to date to date to date to date prophylaxis (PrEP) to prevent HIV during the reporting period TX_NEW: Number of adults and children newly enrolled on antiretroviral therapy DSD 83 - - 50 - - 0 - - 1 0 (ART) 25% TX_NEW_VERIFY: Number of HIV positive persons who were newly navigated into DSD 10 317 4% 4 103 1% 0 2 0% 0 4 treatment TX_CURR: Number of KPLHIV currently DSD 152 - - 136 - - 0 - - 1 0 enrolled on antiretroviral therapy (ART) TX_CURR_VERIFY: Number of KPLHIV 25% currently enrolled on antiretroviral therapy (ART) or documented to be current on DSD 0 301 0% 18 98 18% 0 2 0% 0 4 treatment at a different facility at the end of the reporting period. TX_RTT_VERIFY: Number of HIV positive persons previously on treatment but were DSD 10 34 29% 3 11 27% 0 - - 0 0 N/A loss to follow up and are now re-engaged into treatment TX_PVLS_VERIFY: Number of KPLHIV confirmed as having a VL result documented in the medical or laboratory results/LIS within the past 12 months. And DSD 25 286 9% 5 93 5% 0 2 0% 0 0 the Number of KPLHIV confirmed as having N/A a suppressed VL result (<1,000 copies/mL) documented in the medical or laboratory results/LIS within the past 12 months. COMM_SUPP_RET: HIV positive persons provided with care in the community DSD 112 - - 62 - - 0 - - 1 1 (outside of health facility) to ensure they N/A are retained on ART

EpiC Eswatini Semi-Annual Report (FY21 Q1-Q2 October 2020 to March 2021) 31

Annex B: Impact of COVID-19 on Program Implementation EpiC implementation was affected by COVID-19 and brought great innovation activities for the program to implement while adhering to set restrictions, to help support continuity of KP access to care and treatment. • Program introduced over 200 HIVST condoms and lubricant pick up points at community level, to help bring closure prevention commodities to KP. • Saw 25% increase in growth on the commercial distribution (under PSI/Condoms) • Developed an online IP mapping tool under NERCHA.

COVID-19 Programming Successes

PrEP Targeted Demand Creation ConductPrEP Mobiles, Introduced PrEP Ambassadors

Trueeswatini.com Hybrid Online risk Virtual Peer assessment, Online Engagement appointment based booking, clinic reporting

Home- Based Refills Case Provide ART and Management PrEP refills, along Virtual Peer Navigation with HIV ST and Virtual LCM Confirmation and PEP

However, the program also had challenges with implementation during COVID-19 and to ensure that KP still access prevention, care, treatment, and support. • While in-person meetings were un-paused there were still safety considerations of staff and beneficiaries to ensure that they continue to protect themselves. Emphasis in ensuring that numbers are restricted when having in-person meetings as well as practicing social distances was strengthened even with outreach workers. • The program continued to encourage virtual platforms or engagements where effective, though we have experienced few instances where this is not normal as some KP do not have access to smart phones that have WhatsApp and/or access to internet.

EpiC Semiannual Report (October to March 2021) 32

• Disruption networks: some hotspots closed, moved, became unsafe and the program has seen constant changes along with COVID restrictions (bars, clubs, liquor banning, travel restrictions). All this also impacted commodity distribution but the program re-strategized by identifying safe places by KP residential places to place commodities for them to access. • Dynamics within the KP populations has drastically shifted how they are reached for services. FSWs moved home, hotel-based shifting based on where their clients stay or moved to street- based. MSM are harder to reach as more approach require social outlets. • Capacity building activities and adapting to virtual approaches was complicated, but the team had to help all outreach workers to adapt. Supervision of community outreach workers performance also moved to virtual. • Delayed start-up of training and orientation of community leaders under NERCHA due to COVID-19 restrictions, note was challenge of engaging participants using virtual platforms and that had to wait for the review of the restrictions.

EpiC Semiannual Report (October to March 2021) 33

Annex C: Key Population Investment Fund (KPIF) • CBOs continue to participate in developing mobile outreach schedule and service delivery after, identifying sites based on high risk identified clients in need of services. Post the KPIF award finalization the MOH decided that the KP partners could not lead clinical services, which was previously expected under the KPIF. Thus, all clinical services are recorded under the EpiC program or through The Luke Commission, which is the Clinical Lead under the KPIF. • Reached and profiled 1,434 FSWs, 131 Clients of FSWs, 68 Transgender women and 2,753 MSMs through one-on-one sessions and group discussions. • Promoted safe sex practices by distributing 46,176 male condoms and 39,284 lubricants. • CBOs participated in preparations for an EPOA to be conducted in Q3. • Strengthened use of going online programming to reach more KP: o Through weekly meetings between Rock of Hope, ROH identified gaps in the system and improved them. o Strengthening use of social media platforms to reach KP. o Engaged a social media influencer. o Strengthened ORA management and data use for reporting. • Designed 24 social media posters for different KP groups: MSM, FSW, Trans gender people, shared, posted in all three True Social Media pages which are Facebook, Instagram & Twitter. • Created two Adverts on Facebook and Instagram: ART & PrEP refills with True Eswatini (an online platform that provides information and access to HIV and SRH services) and Psychosocial Support Service which was inclusive of gender-based violence (GBV). • Updated seven IEC Material; including MSM and FSW HIV discussion Guides to be utilized by all the CBO Outreach Team, making it to thirteen documents to date. • Printed six (6) different I.E.C Material document, distributed in True Community Centers and implementing partners for pre-testing, • Four social media post were made each week on Twitter, Facebook, and Instagram as well as the distribution of a total of 202 IEC materials in this entire reporting period. • Implemented the LINK survey to understand client’s satisfaction status when accessing services in the two KP Community Centers and some in the mobile clinic post accessing services by clients. The KP- CBO responsible for implementing the LINK survey, Rock of Hope, conducted a meeting to share the results to the rest of the KP-led CBOs and other partners, including MOH, CANGO and FHI 360 with recommended areas for improvement. • Continued CBOs’ board members capacity building meetings on governance and management through CANGO. • Continued support for capacity development from MPact focused on social media growth. • Support to CANGO on improvement of CBO capacity development structure and feedback, as noted above.

EpiC Semiannual Report (October to March 2021) 34

• Transitioned stigma-reduction activities from Rock of Hope to CANGO to allow activities to align with MOH priorities for this activity. CANGO will provide administrative support to MOH while FHI 360 will continue with TA. CANGO will engage a consultant to assist MOH to implement. • Engaged a PSS Officer and transitioned the PSS office from FHI 360 to HP4M where 53 clients were offered PSS services from across all organizations. o 3 Sexual Abuse cases o 1 Physical abuse o 17 Emotional Abuse cases o 31 unclassified general mental health engagements • Capacity building provided for one KPIF Partner Executive Director (ED) on doing verification on organizational data. • VOOV organogram was revised and shared with the board of directors for review. • All KP partners participated in an annual reporting meeting, including programming specifics around COP 21. • The Executive Director for one KPIF partner was capacitated on the process of verifying the accounting system with skills building by the finance and admin team. • VOOV engaged with a group of sex workers on IEC development and messaging. • There were limited site visits owing to the COVID-19 regulations and adhering to the protocols. Virtual engagements were strengthened, and these were used to engage vigorously on the program and organizational development component. • KPIF Community Engagement Fund (global): Issued Community Engagement grants, up to $72,000 for programming to address structural interventions in Eswatini. An EOI was sent to all KPIF CBOs to share their interest, with the grants meant to expand existing KPIF programming to implement innovative interventions that address structural barriers that key populations face in accessing quality HIV prevention, care, and treatment services. Three partners won the grants and are receiving support towards improving their proposals to help ensure implementation starts in April 2021.

The following Community Engagement Grants were awarded: 1. FSW life skills development by VOOV a. FSW life skills development b. Violence prevention and response c. Stigma and discrimination reduction 2. KP GBV response by HP4M a. Strengthen violence reporting amongst KP b. GBV awareness and prevention campaigns 3. Sibambene sonkhe project by ROH a. Capacity building for social workers b. Sensitizations on violence prevention through virtual outreach c. Provide emergency support to KP

EpiC Semiannual Report (October to March 2021) 35

Annex D: “Our lives have been saved”: How Community-level KP Support on Treatment Continuity has Saved Lives “I was so confused and scared, I did not know what to do, worry and fear was written all over my face. People would ask what is wrong with me because they could see something is bothering me. I thought of going back to Satellite Clinic to ask for re-initiation on ART, but I was not brave to face the nurses because I knew I was wrong to stop taking my pills, let alone stop giving my child as well.” These are words from Sibongile Dlamini, a female sex worker from Ezulwini before receiving support from EpiC outreach worker, Bongekile through peer navigation. Sibongile is one of many Key Population (KP), especially sex workers, who experience challenges in treatment continuity and has interrupted taking treatment. When the program started, most KP were interrupting treatment for different reasons, including socio-economic as well as high mobility during the festive season. The program therefore expanded service provision and support to KP to reduce interruption in treatment. Some of the interventions introduced included: having a focused linkages officer who worked with KP-led partner organizations and program outreach workers (ORWs) to strengthen peer navigation and needed support on the ground. The program also introduced community ART refills both at the two KP community centres (equivalent of drop-in-centres) and through mobile clinic outreach. As a result, continuity of treatment increased as demonstrated in Figure 1 below: Figure 1: Historical numbers of continuity of treatment among KP in the Eswatini KP programSuch achievements in continuity of treatment have Full time linkage to Began providing treatment support community-based continued among KP through close started in Jan 2020 refills and service navigation of clients testing positive provision at 2 DICs through community peer navigation and assisting them to reinitiate if they have disrupted treatment. Continuity of treatment after disruption has been a huge problem as most clients are scared going back to their facilities, fearing health care providers. In FY21, Q1, the program began implementing DDD refills for clients booked during the festive season, to help ensure that clients do not interrupt treatment. Figure 2 below demonstrates the continuing strength of continuity of treatment among KP.

EpiC Semiannual Report (October to March 2021) 36

• Figure 2: The Eswatini KP program's continuity to treatment performance in FY21, Q1&2

Sibongile is one of the KP who have been supported to continue treatment after she had interrupted, and she continues narrating her story. “As I was battling with how to re-start my treatment and my child’s, one day I got an invite for a health talk at Buka. Gugu one my friends who knew about my problems said if I attend the health talk, I might be assisted with getting back on treatment because the facilitator usually brings mobile clinics with nurses who test and initiate people who test HIV positive to treatment the same time. I agreed to attend with the hope that the nurses will understand my situation and allow me and my child to start treatment again. Bongekile was very good, she taught us a lot about HIV treatment and dangers of defaulting treatment. It was a very informative session which made me want to have a one- on-one session with her”. After the session, Sibongile states she had an opportunity to finally speak with the Bongekile, “My turn came, and I formally introduced myself and told her my story.” Bongekile arranged a visit for Sibongile to the Mbabane TRUE Community Centre, one of the KP community centres. At the community centre, she was assisted by a HTS Counsellor and nurse with counselling and ART re-initiation. She states after that she had a challenge was with re-initiating her child to ART and the centre does not provide pediatric services. She continues her story, “I was referred back to Baylor Clinic for medication of my child but then the challenge was on how to get help as the last time I spoke to them about my child, I reported that he is dead so they would close the file and stop calling me. This was a moment I regretted all the lies because my child was really not well, and I could see that he was deteriorating, he needed urgent help.” She spoke to Bongekile again about the child. Bongekile accompanied her to the Baylor Clinic to apologize to the nurses and request them to help my child get back to treatment. The child was re-initiated on ART. Sibongile concludes by stating, “As I speak, we are both on treatment and I have learned a good lesson, I will never stop my medication, and will make sure my child stays on medication for as long as I live.”

EpiC Semiannual Report (October to March 2021) 37

SECTION II: EpiC Eswatini/NERCHA: Community Strengthening Program

A. Background on the Activity

The EpiC Eswatini NERCHA program will enhance the capacity of local government and traditional structures (Chiefdoms and Municipalities) in Eswatini to lead their HIV response by utilizing data and leveraging locally available resources for a well-planned and coordinated effort to attain the goal of ending AIDS by 2022 and to prevent new infections. Specific Objectives include: • Strengthen NERCHA to coordinate the multi-sectoral response at national and decentralized levels. • Equip chiefdom, municipality and inkhundla, and Regional structures with skills and tools to use data to coordinate, lead, own and manage the HIV response at the different levels.

B. Summary of Key Results This reporting period marked the first six months of implementation of the project under EpiC/National Emergency Response Council on HIV and AIDS (NERCHA) 16 . The EpiC/NERCHA program transitioned programming from the prior USAID project HC4, receiving equipment and vehicles starting in November. Eight staff were hired and trained on data management using Community Data Action Platform (CDAP) in November 2021, with the final staff position, the Strategic Information, starting in December 2021. As programming was ramping up, Eswatini began experiencing the start of the second wave mid-December, which was impacted by the identification of the South African variant B.1.351. Routine programming was only able to return on second week of March 2021 when the government relaxed its restrictions on movement and meetings at the community level. COVID-19 impacted and delayed program implementation as the majority of activities require face to face meetings, and trainings to capacitate community leadership on the program.

This reporting period observed project shifts such as transition of responsibilities for data collection and management from Point of Contact (POC) to a more pronounced community cadre (Bucopho). Community Development Committees (CDC) mapping in all the four regions was done to understand gaps in terms of existing community structures which will facilitate smooth implementation of this project. EpiC/NERCHA continued with facilitating Regional coordination meetings with different stakeholders to promote synergistic collaborations and improve efficiencies in HIV response at community, Inkhundla, regional and national level. The program also developed action plans to rapidly accelerate programming in Q2 with spillover effect to Q3.

Below is a summary of FY21 semi-annual achievements:

• Hired nine staff to support EpiC/NERCHA programming • Trained 19 staff on data collection, reporting and analysis using CDAP (DHIS 2).

16 National Emergency Response Council on HIV and AIDS (NERCHA) was created to coordinate and facilitate the National Multisectoral HIV/AIDS response and oversee the implementation of the national strategic plans and frameworks in the Government of the Kingdom of Eswatini.

EpiC Semiannual Report (October to March 2021) 38

• One hundred percent (337/337) of chiefdoms were mapped for the existence and activeness of CDC. • Fifty three percent (177/337) of mapped communities have active CDCs, 31 percent have non- functional CDCs and 16 percent do not have CDCs. • Seventy five percent (133/177) of the active CDCs were oriented on their roles and responsibilities in line with the HIV Response reaching out to 240 chiefdom leaders. • Five CDAP datasets were revised as well to ensure inclusion of the National Minimum Package (NMP) coverage tracking. • Distributed data collection tools to 153 chiefdoms and 14 collected at least one dataset in Q2. • Eighty-nine chiefdoms out of 153 who received data collection tools were mentored on data collection at least once in Q2. • A total of 51/100 Implementing Partners (IPs) were mapped in the four regions. • Regional Coordination meetings held in Lubombo and Hhohho to discuss details related to the HIV Response coordination in line with the NMP. • Developed and reviewed the HIV Response coordination manual to facilitate standard implementation of community activities on HIV response. • Conducted baseline M&E Capacity assessment for NERCHA and developed an action plan to be implemented from Q3. • Migrated SHAPMoS reporting forms to DHIS 2 to facilitate integrated reporting. • Developed a COVID-19 adaptation plan to guide how programming adjustments are required due to the impacts of COVID-19. • Revised workplan and budget to incorporate an additional $50,000 that was added to the program.

C. Support the transition of prime funding and implementation to capable local partners to meet the PEPFAR goal of 70% of funding to local partners by 2020

Strengthen National Level Monitoring and Evaluation Systems

Conduct Desk review & Mapping of the status of CDC in each community While this activity has been traditionally implemented by Johns Hopkins University (HC4) since FY19, NERCHA took over implementation in FY21. In FY19, HC4 focused on strengthening chiefdom leadership through training and ongoing mentorship of Inner Council members and a POC for data collection, partner coordination, and community mobilization. In FY20, HC4 expanded its community system strengthening strategy to capacitate CDCs – as the operational arm of the inner council, with intensive mentorship activities using a revised mentorship guide, supporting continued data review using CDAP. In FY21, NERCHA continued to focus on CDCs with focus on operationalizing the NMP and the Bucopho as the central point for data collection. The transition from POC to Bucopho ensures sustainability of the program since the latter is managed by Ministry of Tinkhundla Administration and Development (MTAD). In Q1 and Q2, foundational activities were undertaken to map and train CDCs in all chiefdoms in partnership with MTAD, develop content linked to data review in preparation for cluster meetings and to create new mentorship tools for cluster and CDC sessions. In Q2, NERCHA worked with MTAD Community Development Officers and chiefdom inner councils to orient and mentor CDCs in operationalizing the HIV response plans.

EpiC Semiannual Report (October to March 2021) 39

As shown in Table 1, 337 chiefdoms in 59 Tinkhundla were mapped. Out of these, 177 (53 percent) had functional and active17 CDCs, 103 (31 percent) were not active and 57 (16 percent) not existing. Table 1: CDC Mapped by Region # of # of Number Total Total % Active Chiefdoms % Non- Chiefdoms of Active Region Number of Number of CDC with non- Functional without an CDC Tink Chiefdoms Mapped functional CDC existing hundla Mapped CDC CDC Shiselweni 15 99 61 62% 29 29% 9 Manzini 18 104 56 54% 29 28% 19 Lubombo 11 55 30 55% 13 24% 12 Hhohho 15 79 30 38% 32 41% 17 Grand Total 59 337 177 53% 103 31% 57

Figure 1 shows distribution of active CDCs by region. Lubombo improved from (36 percent in Q1 to 55 percent in Q2) while Hhohho remained stagnant at (38 percent). Hhohho (38 percent) have less proportion of active CDCs respectively when compared to Manzini (54 percent), Lubombo (55 percent) and Shiselweni (62 percent). This however indicates the amount of work needed in these two regions to activate the CDCs. Figure 1: Active CDCs Coverage by Region

The number of active CDCs oriented improved from (33/177) in Q1 to (131/177) in Q2. During these orientations, a total of 240 chiefdom leadership members were reached with majority (60 percent) being Bucopho (Table 2). Majority of these orientations were done in Shiselweni region (100 percent [61/61]) and the least in Manzini (44 percent). The trainings aim to reintroduce roles and responsibilities of the

17 An active or functional CDC: Meets regularly to discuss development issues at least once a quarter, submit quarterly reports to inner council and have records of their meetings/ minutes

EpiC Semiannual Report (October to March 2021) 40

CDC, reporting structures, and engage them more fully in CDAP through dashboard reviews to update HIV action plans developed. CDC members could not be fully trained on the national minimum package and use of CDAP due to logistical challenges posed by the COVID-19 prevention and control restrictions imposed by the Eswatini government. Main training of CDC members will commence in Q3 but if COVID- 19 restrictions return, virtual and one on one mentorships will be done. Table 2: Chiefdom Leadership Oriented on CDC Roles and Responsibilities by Region

GRAND Manzini Hhohho Shiselweni Lubombo TOTAL Inner Council 3 0 1 0 4 CDC Member 10 0 11 15 36 Bucopho 39 37 53 15 144 Chiefdom Secretary 11 1 0 0 12 Indvuna yemcuba 2 1 0 0 3 Indvuna yenkhundla 1 6 8 0 15 Inkhundla secretary 0 5 8 0 13 Gogo Centre 1 0 0 0 1 Member of Parliament 0 0 2 0 2 Former POC 8 0 0 0 8 Bagcugcuteli (RHM) 2 0 0 0 2 GRAND TOTAL 77 50 83 30 240

By Region Shiselweni Region About 90 percent [90/99] chiefdoms in the Shiselweni region have an existing CDC in which 62 percent (61/99) were active. A total of 29 CDCs are inactive and will be revived in collaboration with the Ministry of Tinkhundla Administration and Development (MTAD). An orientation on HIV response and CDAP will be conducted in Q3 for the CDC members. A total of nine chiefdoms do not have CDCs and the region will work with MTAD in Q3 to facilitate the election of these CDCs by community members. A total of 83 CDCs (inclusive of 61 active) received training or orientation on roles and responsibilities with support from MTAD in this region.

EpiC Semiannual Report (October to March 2021) 41

Figure 2: Active CDC Coverage in Shiselweni Region

Shiselweni Region 12 120% 100% 100% 100% 10 88% 88% 86% 83% 100% 80% 75% 8 80%

6 43% 60% 38% 33% 4 27% 25% 40% 14% 2 20% 0 0%

Total Number of Chiefdoms Number of Active CDC Mapped CDC Active Coverage Rate (%)

Hhohho Region The CDC mapping results showed that about 38 percent (30/79) of CDCs were active in the region. The number of CDC members in most of the CDCs were less than twenty with some even less than 10. Lack of capacity building, limited knowledge of the roles and responsibilities of the CDC and the traditional leaders has affected the performance of the CDCs. There is a need for the revival and or election of CDCs in collaboration with MTAD. Only two (3 percent) of the CDCs, one in Mahlangatane and one in Madlangempisi were oriented on their roles and responsibilities in line with HIV response whilst the other 48 CDCs were oriented on generic roles and responsibilities. Figure 3: Active CDC Coverage in Hhohho Region

Hhohho

10 100% 120% 86% 100% 8 75% 67% 60% 57% 80% 6 50% 50% 60% 4 20% 40% 17% 13% 2 0% 0% 0% 0% 20% 0 0%

Total Number of Chiefdoms Number of Active CDC Mapped CDC Active Coverage Rate (%)

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Lubombo Region A total of 30 (55 percent) of the CDCs mapped were active in this region, while 24 percent (13/55) CDCs were found to be non-functional and 21 percent are non-existent. In Q2, validation meetings with MTAD were done and MTAD has promised to revive all inactive CDCs in the region. Figure 4: Active CDC Coverage in Lubombo Region

Lubombo 8 100% 120% 7 75% 75% 75% 100% 6 71% 67% 5 60% 60% 80% 4 43% 60% 3 20% 40% 2 1 0% 20% 0 0%

Total Number of Chiefdoms Number of Active CDC Mapped CDC Active Coverage (%)

Manzini Region The region finalized mapping of the remaining six CDCs in Q2. Out of the 104 chiefdoms mapped in Manzini region, 54 percent (56/104) CDCs were active while 28 percent (29/104) CDCs were non-functional. The region will work with MTAD to facilitate election of 17 CDCs in 17 communities that did not have a CDC in place during this reporting period. A validation meeting with MTAD was held. MTAD recommended that constituencies such as Kukhanyeni, Mhlambanyatsi, Nkomiyahlaba and Mkhiweni tinkhundla require CDC training for all chiefdoms regardless of the CDC being functional or not given inherent challenges in those areas and also had not been properly trained. Figure 5: Active CDC Coverage in Manzini Region

Manzini 12 100% 100% 120% 83% 10 80% 71% 100% 60% 60% 8 55% 50% 50% 50% 50% 80% 6 38% 60% 4 25% 20% 20% 17% 40% 2 0% 20% 0 0%

Total Number of Chiefdoms Number of Active CDC Mapped CDC Active Coverage Rate (%)

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Develop guidelines for integrating HIV and AIDS into community development initiatives An HIV Response Coordination Curriculum was developed and shared with key stakeholders such as MTAD and PACT for review. The curriculum included topics on the link between Health and Sustainable Development, the National Minimum Package (NMP), HIV Response Coordination, HIV Mainstreaming, CDAP and Gender and Gender Based Violence (GBV), which forms the basis of HIV coordination in Eswatini. Highlights on the HIV epidemic and drives and drivers of the epidemic in Eswatini and roles and responsibilities of CDCs were included in the manual.

Capacity building of Bucopho on data management and use at chiefdom level In FY21, as shown in Table 2 below, NERCHA revised traditional datasets in CDAP to incorporate elements of the NMP, credible data sources such as Education Monitoring Information System (EMIS), Community Monitoring Information System (CMIS) etc. Given logistical challenges in formal training of Bucopho on CDAP data management processes, NERCHA employed a step wedged approach in distributing data collection tools. Priority was given to the 25 PEPFAR priority Tinkhundla with 125 Chiefdoms receiving tools. Second option was given to those Non-PEPFAR priority Tinkhundla (28 chiefdom receiving tools) with an active CDC and lastly those with an inactive CDCs or non-existent. As shown in Table 3, a total of 153 (45 percent) chiefdoms have received data collection tools. Regional M&E teams oriented 152 Bucopho onsite on how to use the tools. Out of 129 chiefdoms in 25 PEPFAR priority Tinkhundla, 125 received data collection tools while 28 out of 208 chiefdoms in Non-PEPFAR priority Tinkhundla also received tools.

Table 3: Data Collection Tool Distribution by Region Number of Number of Bucopho Total # of # of Chiefdoms Chiefdoms Region Trained/Oriented on Chiefdoms Targeted received data Data Collection collection tools Shiselweni 99 53 (54%) 53 53 Manzini 104 39 (38%) 39 39 Lubombo 55 21 (38%) 21 23 Hhohho 79 40 (51%) 40 37 Grand Total 337 153 (45%) 153 152

CDAP Data Capture Status Under normal circumstances, chiefdoms are expected to collect at least 9 out of the 13 datasets in CDAP. However due to delays in data collection caused by COVID-19 restriction, 7 out 40 chiefdoms who received data collection tools in Hhohho managed to collect at least 2 datasets (Births and Deaths and Households or OVC). Shiselweni also observed 4/53 while Manzini had 1/39 and Lubombo with 2/21. After formal training in Q3, chiefdoms will be provided tablets to facilitate for data entry using the DHIS 2 Capture application. Mentorship of Chiefdoms on CDAP Data Management Since tools were deployed without formal training, teams resorted to onsite trainings in March. Supervision and mentorship plans were developed immediately to support the chiefdoms. As noted in Table 3 above, 153 chiefdoms received data collection tools. About 58 percent (89/153) of the chiefdoms that received tools were mentored at least once. Lubombo (100 percent) and Hhohho observed high mentorship with Manzini (10 percent) having the least coverage. A total of 60 percent of the mentoring sessions were done in person while 40 percent were done virtually. In PEPFAR Priority Tinkhundla, 67%

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(52/129) of the chiefdoms received at least a single mentoring session on data collection, capturing and visualization.

Number of Chiefdoms & Number of Chiefdoms Mentorship Mentorship Municipalities Mentored Coverage Coverage Total # of Received Region (%) (%) Tinkhundla Total # of Data 1 – 3 4- 6 7+ Total (Received Vs All Chiefdoms Collection times times times tools) Chiefdoms Tools Manzini 18 104 39 4 0 0 4 10% 4% Hhohho 15 79 40 37 0 0 37 93% 47% Lubombo 11 55 21 21 0 0 21 100% 38% Shiselweni 15 99 53 27 0 0 27 51% 27% Total 59 337 153 89 0 0 89 58% 26%

All mentoring sessions were on data collection and data entry. This was deliberately repeated to ensure that chiefdoms have grasped the concept of data collection and entry. Next phase of mentorship sessions will be done after formal trainings earmarked for Q3. All mentoring sessions were captured in CDAP to facilitate reporting and documentation of investment on these chiefdoms. Coordination of Urban HIV Response In the last two quarters, there have been no activities conducted in the municipalities on coordination of the Urban Response to HIV. However, plans are underway to engage the municipalities since lockdown has been lifted to allow for gatherings. NERCHA plans on engaging Ministry of Housing and Urban Development (MoHUD) in Q3 to formally engage with urban structures of HIV response.

Implementing Partner Mapping against National Minimum Package HIV Service providers mapping against National Minimum Package was initiated in Q1. Service coverage was gauged using 16 HIV services as shown in Figure 6. As at the end of Q2, a total of 51 against an estimated 100 implementing partners were mapped against different HIV services in four regions. In Q3, NERCHA will facilitate a mop-up process of remaining IPs and gap analysis of service provision at community level which will in turn influence resources allocation. In Q3, NERCHA will work with key stakeholders in addressing service gaps identified from these areas.

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Figure 6: IP Mapping Summary

Proportion of Partners Providing Service (n =51)

TB_HIV Treatment PMTCT VMMC HIV Comobities Economic Empowerment Treatment Retention and Viral Load PEP PrEP OVC STI HIV Care and Treatment Condom Promotion and Distribution HTS Stigma & Discrimination GBV SBC

0% 10% 20% 30% 40% 50% 60% 70% 80%

Figure 7 shows NMP coverage by Tinkhundla. Data presented is at end of March and in Q3 the map will be updated with current data. While coverage is relatively high in Manzini, Shiselweni has relatively low coverage rates below 50% in eight of its 15 chiefdoms.

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Figure 7: NMP Coverage by Tinkhundla

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Integrated Reporting Platform CDAP was upgraded from DHIS 2 v2.30 to 2.33 which introduces several updates to the native analytic applications within CDAP. The upgrade also renders single aggregate data visualization, improved mapping tools, a single dashboard with filters as well as combined pivot and line listing within event reports. This will improve use of dashboards by applying filters for different variables for the respective chiefdoms. A total of 200 out of 200 new tablets were also configured with DHIS 2 Capture Android application which will be used by chiefdoms for data entry. SHAPMoS Reporting Forms were configured in DHIS 2 to facilitate reporting by NERCHA regional M&E teams and implementing partners. This means that NERCHA will migrate from using old SHAPMoS system and integrate with CDAP in DHIS 2 as its primary reporting tool. NERCHA M&E and programs team were oriented on using the forms in DHIS 2. Partner orientation will follow in Q3. During the transition phase (FY21 Q1), only 125 chiefdom accounts existed in CDAP. In Q2 an additional 100 chiefdom accounts were created to allow access for new chiefdoms. The addition of new chiefdom accounts also led to the addition in organization units in CDAP from 25 Tinkhundla 59 and from 129 chiefdoms to 327. Capacity development for HIV response stakeholders NERCHA has the responsibility of building capacity of HIV response stakeholders on monitoring and evaluation. To achieve this, NERCHA conducted an internal capacity assessment of Strategic Information Unit. In Q3, NERCHA will conduct a capacity assessment to HIV stakeholders beginning with Deputy Prime Ministers office, CANGO and SWABCHA. The process is aimed at strengthening M&E capacity of these sector coordinating entities to lead HIV response.

Regional level Coordination In Q1 Lubombo and Hhohho held coordination meetings with Community Leadership Engagement Officers (CLEOs) from some of the implementing partners in the region. The meetings aimed at creating collaborations and avoid duplication of activities in order to improve efficiencies in data collection and sharing at chiefdom level. Some of the topical issues discussed were:

• Role of Bucopho on data collection, interpretation and analysis at chiefdom level. • Linkages and interoperability of community-based systems such as CommCare and CDAP to improve on reporting. • Possibility for having one system at community level which the chiefdoms and constituencies will rely on for decision making purposes. • Standardized reporting to NERCHA by implementing organizations. • Collaborative work planning and implementation by IPs operating in the same communities. • Budgeting for Quarterly data review meetings by each implementing partner. Coordination meetings are planned for early Q3 in which implementing partners will also be oriented on the NMP, its implementation and tracking. 5. Strengthen the coordination and collaboration of community actors

At National level in Q2, two collaboration meetings between NERCHA and the Ministry of Health (MOH) Listen Project which is active in 8 chiefdoms in Manzini and Lubombo have been held. Some of the key points discussed were: • NERCHA to take lead in coordinating data collection at chiefdom level and facilitate sharing of these data with the MOH LISTEN team.

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• NERCHA to support the MOH LISTEN with a data management system (CDAP) which will the allow MOH LISTEN team to track both core and custom indicators. • Bucopho will become a pivotal position in disseminating data at community level. Orient Community Coordination Structures on NMP COVID-19 prevention and control measures have delayed orientation of CDCs on the National Minimum Package. Training plans were developed for all CDCs, however restrictions for meetings meant pushing the activity to Q3.

Conduct advocacy sessions with Chiefs and Mayors to support the delivery of HIV services at community and ward level. Chiefs’ meetings have been affected by the COVID-19 regulations such that they were postponed to Q3 anticipating relaxation of regulations. In Q3, advocacy meetings will be conducted at regional level with aim of bringing chiefs and mayors on board in terms of HIV response in their respective communities.

D. Additional Accomplishments to Highlight • Oversight and development of M&E systems and tools: CDAP dataset matrix was revised to include tracking of the NMP. A community reporting form was revised and configured in CDAP for pilot testing in Hhohho Region. The tool will be used for reporting community activities not captured by the traditional SHAPMoS Implementing partner reporting form. • Capacity strengthening and training: M&E and Programs teams were oriented on CDAP and DHIS 2 in general. The aim of the training was to build capacity of new M&E staff on work tools for this project and also have programs teams to have an appreciation of how data is collected, managed and analyzed. Training focused on what is CDAP, how is data captured and analyzed in CDAP. • Conducted a capacity assessment for NERCHA M&E team (individual and group based) to establish baseline values for development of capacity development plans. • Reviewed Multi-sectorial HIV Response M&E Framework and now awaiting validation by the National SI TWG.

E. Management and Operations • Continued the transition from the prior PEPFAR program HC4, with the full transition being completed towards the end of November 2020. • Adapted the workplan to add an additional $50,000 to the program. • Recruited and engaged four senior program officers and four monitoring and evaluation officers that started in November 2020 and one technical advisor for strategic information that started in December 2020. • Absorbed the inventory provided to the program through HC4. • Supported a three-day orientation and training for the staff. • National COVID-19 Control and Prevention guidelines affected implementation of face to face activities. To mitigate this the program will implement virtual engagements for meetings, mapping of implementing partners and mentorships. • Held meetings with MTAD and MoHUD and each ministry promised to assign a point person for the program.

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F. Priority Activities in the Next Six Months (April 2021 to September 2021) During the next six months in Eswatini, the community strengthening program under EpiC/NERCHA will: • Conduct all four meetings Regional AIDS Coordinating Teams, one in each region. • Develop and validate HIV and AIDS multisectoral Inkhundla plan with the Inkhundla council. • Two quarterly HIV Stakeholder Meeting with Inkhundla Council. • Conduct good practice sharing exchange visits between Inkhundla for learning purposes on best practice. • Finalize the Point of Contact engagement processes for all remaining Tinkhundla. • Orient Bucopho, or the relevant points of contact on NMP and CDAP. • Orient CDCs on HIV Response and NMP. • Support Chiefdoms with development of Action Plans, and monitor those that have them completed. • Conduct Community Data collection and analysis. • Hold Collaborative meetings with CLEOs at regional level. • Build capacity of stakeholders on M&E systems. • Follow up with MTAD on reviving the CDCs which is under their Ministry.

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Annex A: Performance Monitoring and Evaluation Matrix

Performance Status Comment PEPFAR support % target Indicators (PEPFAR & Custom) Annual Type Q1-2 achieved Target to date Non PEPFAR 100% 2% 2% Non PEPFAR Priority Tinkhundla Proportion of chiefdoms mentored on HIV response PEPFAR 100% 67% 67% PEPFAR Priority Tinkhundla # of chiefdoms with data utilization frameworks 337 0 0 # of communities conducting data reviews 337 0 0 # of Communities have annual HIV plans with 75 0 0 measurable targets that have been analyzed quarterly. # of tinkhundla supported to develop data utilization 59 0 0 Activity affected by delayed training frameworks of CDCs due to COVID-19 Prevention # of regions supported to develop data utilization 4 0 0 and control Regulations frameworks Proportion of regions with operationalized Data 100% 0 0 Utilization Frameworks # of Regions have annual HIV plans with measurable 100% 0 0 targets that have been analyzed quarterly. Bucopho not yet formally trained but Program managed to reach out Proportion of chiefdoms/municipalities with updated to a few chiefdoms and conducted 100% 37% 37% community profiles in CDAP one on one orientations. Trainings to be conducted in Q3 after COVID- 19 restrictions have been lifted Service provision maps to be # of communities with maps of community resources 337 0 0 developed in Q3 Mapping Process completed. Now % IPs or community structures mapped reporting 50% 50% 100% doing mop up of partners who have program data at the community level Mapped Mapped not submitted # of communities reporting HIV services newly supported/introduced at the community level (the additional 34 tinkhundla can be reported here only after 350 0 0 the 25 priority tinkhundla have 100 percent annual coverage) # of stakeholders trained on M & E (in all 59 tinkhundla) 20 0 0 # Number of quarterly HIV Stakeholders meetings with the Inkhundla Council where data is used to support decision making and activities. (the additional 34 59 0 0 tinkhundla can be reported here only after the 25 priority These activities will operationalize tinkhundla have 100 percent annual coverage) once chiefdoms have been trained. Proportion of chiefdoms/municipalities that hold a community activity informed by data from CDAP or 100% 0 0 mentoring sessions Proportion of chiefdoms/municipalities that utilize data 100% 0 0 to make decisions # of communities with documented requests for additional services based on gaps identified during data 35 0 0 review process # of communities that received the services that have 35 0 0 been requested

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SECTION III: EpiC Eswatini Condom Program

A. Background PSI, under EpiC, will support the MoH to steward the condom program for the final year under PEPFAR funding. PSI will work with key stakeholders to transition condom programming to MOH and close out the project. Storage of scented condoms and lubricants at PSI will be transitioned and handed over to CMS. PSI will also support quarterly TWG meetings to ensure smooth transition of condom activities to MOH. The program will also distribute free condoms to targeted retail outlets and partners to reach priority populations, conduct condom promotion activities to increase access and use and support priming of commercial condom sector as part of its support to transition the condoms program to the MOH. B. Summary of Key Results During this reporting period 4,506,000 male condoms were distributed, of which 56 percent went to retail outlets and 44 percent to partners. PSI continued to promote condom access and use on social media and radio. Condom sales continued through the self-sustainable model developed with PSI/South Africa (SA). An increase of 33 percent in condom sales was seen during the shift from the integrated retail distribution model to the full commercial self-sustainable model. Commercial lubricants were introduced to the product portfolio, further providing choice and convenience to consumers. PSI is working closely with the Central Medical Stores (CMS) and the Sexual Reproductive Health Unit (SRHU) at the Ministry of Health (MoH). As part of the technical assistance to the MoH to steward the condom program, scented condoms were moved from the PSI warehouse to the MoH’s CMS, as per the national condom distribution guidelines. PSI supported the CMS to distribute condoms to retail outlets and partners.

Social media activities were intensified during this reporting period, due to ongoing COVID-19 restrictions. International Condom Day, which typically coincides with Valentine’s Day, was commemorated during this reporting period. To celebrate these two occasions the GIGI page ran a competition to engage young people. Below is a summary of FY21 semi-annual achievements.

• 4,506,000 male condoms were distributed, 53 percent (4,506,000/8,531,000) of the annual target. • 184 posts published on the Got it? Get it Facebook page, reaching a total of 35,440 adolescents. • Moved 100% of all scented condoms from the PSI warehouse to the MoH’s CMS. • Condom social enterprise sales at Ruchi increased by 33 percent (441,072/331,992) • Introduced a new lubricant product introduced to the market.

C. Key Results by Objective

Objective 1: Attain and maintain HIV epidemic control among at-risk adult men, women and priority populations (PP)

Activity 1: Provide technical support to MoH and transition condoms to CMS In FY21 Q1, PSI supported the MoH to steward the condom program. PSI worked with the CMS and the SRHU at the MoH to move the storage of scented condoms and lubricants from the PSI warehouse to CMS as per the national condom distribution guidelines. The national condom distribution guidelines stipulate that all free public sector condoms should be stored at CMS. A total of 4,110,000 scented condoms were transferred to CMS of which 2,079,000 and 2,031,000 were vanilla and strawberry respectively. In

EpiC Semiannual Report (October to March 2021) 52

addition, 166,000 lubricants were transferred. PSI draws down stock from CMS to distribute to outlets and partners. The ordering system for scented condoms still remains with PSI as they are targeted for key populations.

In Q2, PSI supported the MoH to develop a condom campaign dubbed “Lemhlophe” which aims to promote the uptake and use of non-branded white wrapped condoms. The campaign is targeted at the youth, adult women and men to use the white condom. Previous distribution data and the UNFPA 2013 Rapid Assessment showed there was very little preference for plain no logo condoms. The uptake of these condoms was low hence the shift to Protector Plus. The country received a consignment of over 10 million plain white no-logo condoms where promotion is required to stimulate demand. PSI worked with other condom partners as well as the National Emergency Response Council on HIV/AIDS (NERCHA) to develop the campaign and the Senior Management Team at the MoH approved the campaign. The roll out of the six-month campaign is currently on going. The “Lemhlophe” campaign will be rolled out from April 2021 and includes channels like social media, radio adverts, tv adverts, posters and billboards. Figure 1: Creative visuals for ‘Lemhlophe’ campaign

To ensure efficient implementation of activities under the National Condom TWG Workplan, PSI facilitated virtual meetings for the TWG to enable them to track progress and inform strategic decisions for the activities. Meetings have been held on a weekly basis for the core-TWG team and are also scheduled quarterly for the larger TWG team.

Activity 2: Distribute free condoms to targeted retail outlets and partners to reach priority populations PSI has an FY21 annual distribution target of 8,531,000 male condoms with 65 percent going to retail and 35 percent to partners, in 4 regions. In Q1, the distribution quarterly target was not achieved (85 percent) as some outlets were still closed and fewer outlets needed refills as there had been intense distribution in Q3 and Q4 of FY20. In Q2, PSI exceeded the quarterly target (126 percent) as the partial lockdown and restrictions were relaxed. Most outlets, such as bars and bottle stores, were in operation. High demand continued with partners as they continued to implement their various programs and distribute condoms to end users. Overall, at Semi Annual Progress Report (SAPR), PSI distributed a cumulative total of 4,506 000 condoms, reaching a total of 106 percent of the semi-annual target and 53 percent of the annual target.

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Figure 2: PSI Condom Distribution, by quarter and overall, FY21

5,000,000 140% 4,506,000 4,500,000 126% 4,265,500 120% 4,000,000 106% 3,500,000 100% 3,000,000 85% 2,688,000 80% 2,500,000 2,132,750 2,132,750 60% 2,000,000 1,818,000

1,500,000 40% 1,000,000 20% 500,000 - 0% Q1 Q2 Overall

Target Actual % achievement

Partner distribution: PSI distributed condoms to different partners who then distribute them directly to the end user through the various programs they implement. Of the total distributed, 1,995,000 condoms (44%) went to XX/35 partners (Table 1), achieving 133% of the partner semi-annual target (Figure 3) and 67% of the annual target. The target was exceeded due to an increased demand of condoms from partners, as most of the distributing outlets were only fully functional in the relaxed COVID-19 lockdown. The increased demand was also driven by the World AIDS Day commemoration that many partners participated in as well as integration in other partner-led activities such as decentralized drug distribution.

Retail distribution. A total of 2,511,000 (56 percent) male condoms were distributed to retail outlets during this reporting period, reaching 91 percent of the semi-annual target (Figure 3) and 45 percent of the annual target. The target was not achieved due to the COVID-19 pandemic and restrictions in travel to some outlets. Some outlets such as bars and bottle stores were closed. Furthermore, most of the distribution had been done in Q3 and Q4 of FY20 to ensure outlets had adequate supply. As a result, in Q1 of FY21, some outlets had stock available with fewer refills being done this reporting period.

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Figure 3: FY21 SAPR Condom Distribution by Partner vs Retail

3,000,000 2,765,500 140% 133% 2,511,000 2,500,000 120% 1,995,000 100% 2,000,000 91% 1,500,000 80% 1,500,000 60% 1,000,000 40%

500,000 20%

- 0% Partner Retail

Target Actual % achievement

A total of 378,000 lubricants were distributed during this reporting period targeting key populations with majority (80 percent) going to partners and the rest to retail outlets frequently used by key populations. Furthermore, a total of 34,000 female condom have been distributed. Female condoms have been moving slowly during the pandemic due to the lack of mid-media promotions. A lot of people are not aware of how to use female condoms. Mid-media promotions provide demonstrations and stimulate the demand for the product. Distribution was also affected by closure of some retail outlets in the country during the partial lockdown.

Activity 1.3 Conduct condom promotion activities to increase access and use PSI uses mass, social and mid-media platforms to promote condom access and use. Mid-media promotions have been suspended since March 2020, due to the COVID-19 pandemic, as they attract large numbers of people. PSI intensified condom messaging by continuing to implement the condom category branding promotion strategy dubbed Got it? Get it (GIGI) using mass and social media. On social media, PSI implements a comprehensive social media strategy focusing on promotion of services and product uptake among targeted populations. To promote condom use and encourage positive behaviour change communication, PSI manages GIGI pages on Facebook, Instagram and Twitter. Social media activities were intensified during this reporting period, due to ongoing COVID-19 restrictions. In FY2021 SAPR, 184 posts have been published on the Got it? Get it Facebook page reaching a total of 35,440 adolescents with condom messaging. There have been 3,147 active engagements and 154 adolescents who were referred and accessed condoms. International Condom Day was commemorated virtually during this reporting period which coincided with Valentine’s day. To celebrate these two occasions the GIGI page ran a competition

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to engage young people. The post reached 1,100 people with 167 engagements in one week. This shows that the audience is ‘engaged’. To supplement the reach on Facebook which has the wider audience reach on social media in Eswatini, 67 posts were published on Instagram reaching 1,830 users, as well as posts on Twitter that reached 647 users. In addition, a total of 60 radio slots were used to flight condom messaging on Eswatini Broadcasting Information Service (EBIS) 1, 2 and Voice of the Church (VOC) radio channels. These activities were conducted between the period of November 2020 and December 2020, in preparation for the festive season, as well as in February and March 2021, to commemorate International Condom Day and Valentine’s Day.

Activity 1.4 Support priming of commercial condom sector

In COP 18, PSI/Es established a partnership with PSI/SA to prime the market and grow the condom commercial sector with in-kind support from USAID. The main focus was social enterprise condoms Trust and Lovers+ as they are more affordable in the market. A route-to-market strategy was established and integrated model used where the existing condom distribution team also sold condoms to retail outlets. The sales team was attached to the main wholesaler in the country, Ruchi, to provide promotion support and sales. In COP19 the partnership Table 1: Ruchi sales to retailers continued with a focus on PSI/SA Integrated Self-sustaining transitioning out of USAID support. A self- model model sustaining model was then developed with Product line FY20 Q1-Q2 FY21 Q1-Q2 PSI/SA taking over all costs borne by USAID. Trust Regular 41,544 56,808 The model included a dedicated sales team to Trust Studded 184,176 226,800 focus on condom sales, Ruchi wholesalers and Trust Scented 23,616 32,616 other key accounts. The transition was completed by the end of COP19. Trust Extra 32,184 51,480 Lovers+ Regular 9,288 11,016 In COP20, PSI/SA now functions Lovers+ Coloured 16,632 20,232 independently with admin support from Lovers+ Ribbed 9,432 11,952 PSI/Es having taken over all costs previously Lovers+ Ultra 7,272 11,448 borne by USAID. The sales team focuses solely Lovers+ Delay 7,848 17,568 on condom sales. Ruchi sales, as the major LP Smooth 12s - 1,152 wholesaler, are used as a proxy to indicate Total 331,992 441,072 market performance. Table 1 shows sales during the period with integrated model and current self-sustaining model.

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PSI South Africa

PSI South Africa PSI eSwatini Warehouse

Sales Coordinator Distribution & Sales Coordinator

Ruchi C&C Manzini C&C Powertrade Price RiteTrading

Provide Demand Provide Demand Provide Demand Sales Agents (3) Creation Only Creation Only Creation Only 4 Sales and Provide Demand Provide Demand Provide Demand Marketing Agents Creation Only Creation Only Creation Only All Regions

All Regions

Figure 1a: Integrated model Figure 1b: Self-sustaining model

In the integrated model, Figure 1a, PSI/SA received in-kind funding from USAID to support the sales team that was integrated with condom distribution. The support also covered the use of the warehouse as the condoms moved from PSI/SA to PSI/Eswatini warehouse. A self-sustained model, as shown in Figure 1b, was developed where PSI/SA took over all costs namely sales team and transport. There is limited use for the warehouse as condoms now move from PSI/SA directly to wholesalers. The warehouse is now use solely for promotion items with PSI/Sa covering the costs. As of September 2020, the sales team focus was no longer integrated with condom distribution but focused solely on sales.

During this reporting period, condom sales showed a percentage increase of 33 percent when compared to the same period the previous year. This shows the increased performance of the new model, where the sales team is focusing 100 percent on sales. During the same period last year, the team was integrated, doing both free condom distribution and sales. Sales are expected to increase in this model, so that the gains from the integrated phase are not lost. PSI/Eswatini will continue to work with PSI/SA to facilitate a smoother market penetration of the commercial condoms in the country.

During Q2, lubricants were introduced to the commercial market. A total of 72 lubricants were sold to retail outlets. PSI/SA also placed condom adverts through digital screen, advertising to promote the Lovers plus and Trust brands.

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D. Management and Operations

Human Resources: The condom programming under PSI is one activity within the larger PSI Eswatini office. The positions noted below are not specific to the condom program, but they support different aspects of the program, thus noted below.

• Resignations: o Strategic Information Director o Procurement Manager o Marketing Manager o Receptionist • New employees o Administration Coordinator o IT Officer • Planned hires in the next three months o Strategic Information Director o Marketing Manager

Operations: • PSI received a branding waiver from FHI 360 to continue use of GIGI branding instead of EpiC. GIGI branding has been used in Eswatini for over 5 years to increase uptake and use of condoms especially to the youth. Any change would affect the acceptability and visibility of the branding. A request was made to USAID, through FHI # which was granted. • Three vehicles were disposed from SIFPO 2 to EpiC.

E. Priority Activities in the Next Six Months (April 2021 – September 2021) During the next six months in Eswatini, the condom program under EpiC will: • Support MoH with condom stewardship in the country • Implement the “Lemhlophe” campaign’ • Distribute condoms to retail outlets and partners • Continue with condom promotions • Support condom Trust and Lovers+ sales • Implement the USAID EpiC potential new scope of work on COVID-19 Vaccine communication campaign

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Annex A: Impact of COVID-19 on Implementation

Implementing Current Activity: Proposed to Pause or Status Indicators Proposed COVID-19 Adaptation Estimated Budget to Partner Modified or Ongoing Affected [or indicate if activity will be paused] be Re-directed / Reprogrammed PSI/Eswatini Activity 1: Provide technical support to MoH and transition condoms to CMS PSI/Eswatini Transition condom storage to CMS Completed None Activity completed in Q1 n/a PSI/Eswatini Support condom TWG meetings Ongoing None Physical meetings paused in COP19. Virtual meetings are n/a conducted PSI/Eswatini Activity 2: Distribute free condoms to targeted retail outlets and partners to reach priority populations PSI/Eswatini Distribution of condoms and lubricants to retail Ongoing Custom Condom distribution deemed by MOH as an essential service, n/a outlets and partners will continue with adherence to COVID 19 prevention measures. Agents will practise social distancing, wear masks and sanitise hands during delivery. This activity has minimal risk as there is limited interaction with people PSI/Eswatini Activity 3: Conduct condom promotion activities to increase access and use PSI/Eswatini Run condom promotions using digital media Ongoing None Continue with condom promotion on digital platforms n/a platforms PSI/Eswatini Run condom promotion adverts on radio: Ongoing None Continue with radio adverts n/a ongoing PSI/Eswatini Conduct mid-media promotions in Paused None Paused as the activity attracts crowds of people. Focus will be n/a communities: paused on radio and digital platforms PSI/Eswatini Activity 4: Support priming of commercial condom sector PSI/Eswatini Generate sales from wholesalers around the Ongoing None Activity ongoing as it can be conducted virtually with limited n/a country interaction with people. PSI/Eswatini Generate sales from retail outlets in all four Ongoing None Activity ongoing as it can be conducted with limited interaction n/a regions with people. COVID 19 regulations to be adhered to. Agents will wear masks, practice physical distancing and sanitise hands. PSI/Eswatini Merchandising and distribution of POS Ongoing None Activity ongoing as it can be conducted with limited interaction n/a materials to outlets with people. COVID 19 regulations to be adhered to. Agents will wear masks, practice physical distancing and sanitise hands. PSI/Eswatini Provide technical and admin support to Ongoing None Activity ongoing as it can be conducted virtually. n/a commercial condoms

Annex B: Performance Monitoring and Evaluation Matrix Population Group Indicators (PEPFAR & PEPFAR Annual % target Custom) support Type Q1 Q2 Year to Date Target achieved to date Male condoms distributed CUSTOM 1,818,000 2,688,000 4,506,000 8,531,000 53%

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