HIV Services and System
Strengthening Project – HS3
BILATERAL AGREEMENT NO. 72051719CA00002
DOMINICAN REPUBLIC QUARTERLY PROGRESS REPORT JANUARY 1 TO MARCH 31, 2020
Health System Strengthening and HIV Services (HS3) Project Quarterly Progress Report January 1 to March 31, 2020
1. INTRODUCTION HIV Services and System Strengthening (HS3) is a five-year, global project funded by the President's Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID), with a period of performance from April 24, 2019, to April 23, 2024. This quarterly progress report covers HS3 activities in the Dominican Republic (DR) from January 1 to March 31, 2020. The project works closely with a local health system strengthening partner (Gestión e Innovación en Salud – GIS), USAID, CDC, the National Health Service (SNS), the National HIV/AIDS Commission (CONAVIHSIDA) and the General Directorate for the Control of Sexually Transmitted Infections and AIDS (DIGECITSS). The following table describes the collaborative activities between the HS3 Project and partners.
Partner Collaborative Activities GIS Supports HIV products supply management, quality of logistic information which feeds decision making, transportation of HIV laboratory samples and delivery of results SNS Transportation of CD4 and viral load results. Update portfolio service manual including HIV services. Refresher training on updated protocols for HIV treatment CONAVIHSIDA Technical support to improve HIV variables related to prevention, care and treatment in the national database DIGECITSS Updating HIV prevention, care and treatment guidelines. Dissemination of new treatment directives. Training of personnel at national and provincial levels
HS3 works under four priority pillars which focus on filling existing gaps in HIV prevention, case finding, and treatment, and on building long-term sustainability to attain and maintain epidemic control: ● PRIORITY PILLAR 1: Expanding Access to HIV Services for Focus Clients (FC)1. ● PRIORITY PILLAR 2: FC community approaches strengthens linkages. ● PRIORITY PILLAR 3: Institutional reform to eliminate policy constraints. ● PRIORITY PILLAR 4: OVC program to serve FC Families.
Key Population Incentive Fund’s (KPIF) and HS3’s goals align closely and are intended to complement existing efforts to improve programs for KP, specifically female sex workers (FSW), Men who have Sex with Men (MSM), and transgender (TG). KPIF promotes the acceleration of high-quality HIV prevention and treatment services for KP and extends the ability for local KP-led, trusted and competent implementing partners (IPs) to contribute to PEPFAR's KP scale-up of differentiated HIV prevention,
1 Defined as migrants from Haiti and their descendants living in the Dominican Republic
care, and treatment services. KPIF funds support greater involvement of local organizations at the community and national level while scaling up innovative, evidence-based strategies to achieve epidemic control for KP.
In FY20, HS3 has been implementing its COP approved activities, as well as KPIF programming in the geographic areas described in Table 1. Annex 1 illustrates the CSO-health facilities network implemented in Q1 and Q2, as well as the new network that will be implemented from Q3 onward. Changes to the sites in the network were based on FC, HIV positive burden analysis, and made to support high volume sites more efficiently and effectively. Support for KPIF-funded sites did not change. Four additional CSOs were sub-grantee in Q2 (Instituto Dominicano de Cirugía de Piel (IDCP), Aid for AIDS, and Batey Relief Alliance (BRA Dominicana) to support service delivery, and Heartland Alliance to provide legal support to FC prioritizing PLHIV FC).
Table 1. Number and type of HS3 supported sites by province, and funding source
Province Q1 Q2 Sub Funding GoDR HTS- GoDR HTS CSO HTS and GoDR HTS- GoDR HTS CSO HTS and granted source only site and ART site ART site only site and ART site ART site CSO (total number) Santo Domingo 7 4 2 7 4 2 6 COP/KPIF Monte Plata 0 2 1 0 2 1 1 COP Puerto Plata 3 1 1 3 1 1 2 COP Valverde 3 1 0 3 1 0 1 COP La Romana 0 1 1 0 1 1 2 KPIF Total 13 9 5 13 9 5 12
2. SUMMARY OF KEY RESULTS
Annex 2 provides comprehensive information on the progress for Q1 and Q2 and semi-annual cumulative progress towards PEPFAR targets as of March 31, 2020.
HS3 progress concerning the targets is summarized in Figures 1, Figure 2, and Figure 3 where the red- dotted line represents the semi-annual target of 50%.
Some of the Q2 activities and their results have been affected by the COVID-19 pandemic. The DR’s first positive patient was identified on March 1, 2020, which led to a national quarantine which went into effect on March 19 until the present. Hence, Q2 achievements refer mostly to services offered in January and February 2020. Community HTS halted in March, while ART services continued and were partially offered at a community level to refill medications for those currently on treatment. It is anticipated that the COVID-19 pandemic will have a greater impact on Q3 achievements.
Key highlights from Figure 1 show that PP Prev. reached 18%, while community HTS POS non-index and index reached respectively 13% and 2% among FC. Slightly better achievements are shown at the facility level with HTS POS at 21% and 23% on non-index and index testing, respectively.
Among the 24,083 individuals who received HTS, 13,031 (54%) were FC; of those, 470 tested HIV positive (4% of positivity rate). Community testing yield increased from 2% in Q1 to 3% in Q2 and remained stable at 5% at 27 of HS3-supported facilities. Variations in case detection rate were observed among sites: ADOPLAFAM and Aid for AIDS in Santo Domingo reported 6% (1,200/77) yield among FC tested at the community level, while selected public health facilities yielded up to 18%, like the Bogaert Hospital in Valverde province. The first yield was driven by rolling out Enhanced Peer Outreach Approach (EPOA) with greater fidelity, the second one resulted from a generally higher yield in the Valverde region. Index testing continued representing 1% of the overall testing, yielding 22% on average. This service was offered by 11 health facilities (5 CSO-led and 6 public facilities) and 4 CSOs at the community level (ADOPLAFAM, IDEV, REDOVIH, CEPROSH, Bra Dominicana).
In response to the statement above, HS3 will put more effort in Q3 to roll out EPOA with fidelity and will scale up index testing.
Although only 6% of the annual TX NEW target among FC was met, the ART initiation rate increased to 49%, as compared to 30% in Q1. This may have resulted from the rollout of incentivized ART for HIV positive FC, which provided a stipend for transportation to help beneficiaries travel to ART clinics, food supplies, and a pre-paid SIM card which enabled the project to continually reach them with adherence counseling messages.
Figure 1. Progress Towards FC-PEPFAR Annual Targets, by Quarter, FY20
Annual Target 5,093 256 1,279 1,421 20,116 554 2,768 51,267 3,076 63,503
As shown in Figure 2, the progress to target was met on the number of ART clients currently on treatment (TX CURR), 99% (compared to 95% in Q1); 88% of the target for ART clients with a documented viral load (VL) (TX PLVS Den); and 82% of the target for virally suppressed ART clients (TX PLVS Num).
By the end of March 2020, the project reported 13,155 clients currently on ART at 14 HS3-supported ART health facilities; 80% had a documented VL test within the last 12 months and among them, 84% were virally suppressed (equal or below 1,000 copies).
Only 2% of the target on ART clients screened for TB (TX TB) was met, while the target on TB treatment was surpassed (TX TB POS). This translates in 266 ART clients who received a TB screening and 77 who were diagnosed with TB and started treatment. Among 360 ART clients for whom TB was ruled out and who started isoniazid-based TB Preventive Therapy (TPT), 147 (45%) completed the 6-months of prophylaxis. As a result, more efforts will be placed on monitoring TB screening and supporting TB-HIV collaborative activities.
For GEND GBV, only 13% of the annual target was met due to a delayed start-up of this service. Sites were assessed for the eligibility criteria, gaps had to be closed for services that needed to be provided and were not available, and staff capacity needed to be increased. It is expected that starting from Q3 more sites will become operational, resulting in increased service coverage.
Figure 2. Progress Towards All Pop-PEPFAR Annual Targets, by Quarter, SAPR FY20
Annual Target TB_PREV DEN 5,538 TB_PREV NUM 4,986 TX_TB_POS New ART 53 TX_TB_POS Already ART 19 TX_TB_Den New ART 2,651 TX_TB_Den Already ART 10,660 GEND_GBV ALL 2,025 TX_PVLS_DEN TOTAL 12,012 10,811 TX_PVLS_NUM TOTAL 13,336 TX_CURR TOTAL 0% 20% 40% 60% 80% 100%
In relation to KPIF, progress towards targets (Figure 3) shows that the project is surpassing its target for testing, non-index, FSW, and MSM, reaching 57% and 52% of the annual target respectively.
Facility HST_TST_Pos (non-index) for FSW is at 17% progress to target identifying 9 FSW in Q2. This low percentage is due to a case detection rate of 1% against a target yield of 7%, a lack of testing through social networks (e.g. EPOA), and insufficient index testing. This small number also has impacted the TX_New targets for FSW which is at 25%. The project will work directly with KPIF grantees to ensure those FSW identified as positive are initiated on treatment by rolling out ART initiation support (approved project SOPs) as well as guaranteeing support from a trained peer navigator.
Facility HST_TST_Pos (non-index) for MSM is at 53% progress to target identifying 51 MSM in Q2. MSM continued to have a high ART initiation rate at 84%, reaching 82% progress to targets. The project will continue to scale up EPOA and peer navigation with MSM to increase ART initiation to 95% in FY20.
Index testing, across all populations, falls short of targets in both FSW and MSM populations, reaching 13% and 23% progress to target respectively. Index testing is not being done at scale, the MSM and FSW
facility Index_POS targets for both FSW and MSM were not met, reaching 11% and 32% respectively. Although MSM saw a positivity rate of 30% (6/20) through index testing, the project did not identify any positive FSW in Q2 through index testing as only 9 were tested; for both populations, index testing was insufficiently rolled out. This intervention is being immediately scaled up. The project is working with KPIF grantees to better understand this issue and provide TA to ensure index testing is being implemented at scale and with fidelity.
Figure 3. Progress Towards KPIF-PEPFAR Annual Targets, by Quarter, FY20
Annual Target 89 113 34 170 189 2,807 27 134 149 2,205
Q3 Plans to address challenges
● The project will scale up personalized testing approaches (EPOA and index testing) to increase case detection and to respond to the COVID-19 crisis; testing FC men at workplaces will also be fast- tracked, depending on COVID-19 related restrictions. ● An orientation on motivational interviewing will be rolled out to health care workers and peer navigators to refine their communication and counseling skills, particularly when offering index testing and explaining the ART benefits. ● By using existing social media platforms (eg. Facebook and Instagram), the project will roll out surveys with the beneficiaries to better identify their needs and design service delivery modalities that meet their expectations; the surveys will focus on barriers and enablers to ART initiation and adherence ● Support to scale up DTG transition and MMD will continue along with close collaboration with GIS on the supply chain management (SCM) to ensure uninterrupted availability of medications ● The team will work closely with the Ministry of Health to ensure that new laboratories (other than the national Laboratory recently designated to COVID-19 testing) will be networked to HS3- supported ART clinics, to ensure availability of VL testing
● HIV positive FC who did not initiate treatment and ART those FC who missed their clinic appointment or were lost to follow up will continue being traced through the peer network; weekly reports on the status of these activities will be developed and used for programming; the project will focus on strengthening the FC case management and will prioritize sites that contributed the most to the loss to follow-ups, such as CEPROSH and Bogaert Hospital. ● The project will increase the focus on ensuring all ART clients receive a TB screening even when receiving ART at the community level and that the 6 months TPT course is completed. ● The M&E team will closely work with the counterparts at ART clinics to ensure that information is regularly updated into the FAPPS, to increase the quality of the reported data.
The HS3 project is committed to rolling out the Q3 planned actions and will continue striving towards meeting the targets, however, since as of yet, COVID-19 does not appear to be under control in the Dominican Republic, it is anticipated that the pandemic will continue to jeopardize the service delivery and negatively impact the progress. Data validation and data quality
For achieving greater efficiency and quality in the reported data, HS3’s M&E team is taking steps to strengthen and use the National Reporting Systems. Starting in Q3, all community tests reported will be entered in the Registry of Key Populations (SIRENP). Also, HS3 will focus on strengthening the data entry process of ART clinical records into the national ART database (FAPPS) and making data verification by comparing the data in the paper-based client’s file with the data entered in the FAPPS at each HS3- supported site.
To ensure data consistency, completeness and correctness across national M&E tools, the HS3 M&E team also continued to compare the data entered into the national HIV testing register to the HTS data report and the data entered into the FAPPS for those tested HIV positive and enrolled into ART service; similarly, the index testing cascade was validated by ensuring, for example, that information in the contacts’ information form and the index testing register are consistent and complete; TB data were triangulated by referring to the TB register, the ART paper-based client's file, and the FAPPS; VL data were verified by checking for any pending test result at the laboratory, any paper-based test result in the ART client's file which hasn't been entered yet.
HS3 continued working with the SI team from FHI360 headquarter to set-up the District Health Information Software (DHIS2); this is an open-source software platform for data entry, reporting, analysis, and dissemination of data used across several FHI360 projects. The DHIS2 features automatic dashboards to support decision-making processes on a daily, weekly, monthly, and quarterly basis. The dashboards will meet the data needs of the HS3 team working across different levels of the system from the site through provincial and national levels. The DHIS2 will be fully operational in FY21 and onwards. This system will increase data quality because the data will be entered directly and in real-time by the site-level data clerks. The date entry will be managed by the HS3 SI team using this same platform.
3. KEY RESULTS BY OBJECTIVE
3.1 PRIORITY PILLAR 1: Expanding Access to HIV Services for FC
3.1.1 HIV prevention Interventions to FC
During the period of October 2019 and March 2020, a total of 14,341 FC received standardized HIV prevention intervention(s) at the community level. The standardized HIV prevention intervention(s) include educational session/material on HIV prevention, condoms and lubricants, and an HIV test or referral.
Figure 4 below shows that cumulatively among the 17,108 FC that received a community-based HIV test, 14,341 (84%) were also reached with community-based HIV prevention education. (PP PREV) Figure 4. HIV Prevention Intervention to FC, SAPR FY20
18,000 17,108
16,000 14,341 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - HTS_TST PP_Prev
Conclusions and Opportunities
● Currently, HS3 is implementing PP_PREV by targeting small group testing interventions in the community at validated hot spots as well as EPOA to reach high-risk FC. During these interventions, HIV prevention information is given to participants through a peer educator, and condoms and lubricants are distributed. HIV testing is offered on-site, but if a client does not feel comfortable in receiving an HIV test on-site, a referral is provided, and the peer educator follows up with the client to ensure the client has access to the HIV test. However, due to clients not giving correct contact information and or changing contact information, it is not always possible for the peer educator to verify if the client has accessed the referral. ● The project is moving towards more personalized approaches to testing to not only increase the number of tests being accessed but also in response to the COVID-19 crisis. Through the scale-up of personalized interventions such as EPOA and index testing, the project should see an increase in the percent of those reached to those tested in upcoming quarters.
3.1.2 HIV Testing Service
During FY20 Q2, at 27HS3-supported sites, a total of 23,796 beneficiaries (12,728 FC, 783 MSM, 23 TG, 624 FSW, 9,638 other population) were tested for HIV, through the facility (15,092 beneficiaries) and
community-based services (9,849 beneficiaries), through the index and non-index testing (Figure 5); over half of all beneficiaries who received HTS, were FC (53%) and 63% of the overall beneficiaries were tested at the facility level, mostly being from other populations who self-referred to facility-based testing sites.
Figure 5. HTS_TST index and non-index, by testing venue and population, Q2 FY20
Among all populations who received HTS, 21-22% is among ages 20-24, while 18-21% is among ages 25- 29 and 12-13% is among ages 30-34; so, ages 20-34 represent half of the total population who received HTS (Figure 6).
Figure 6. HTS_TST Age/Sex Pyramid, All Populations, Q2 FY20
50+ 1,609 1,348 40-49 1,262 1,170 35-39 980 1,029 30-34 1,375 1,639 25-29 1,956 2,657 20-24 2,280 2,888 15-19 1,346 1,886 10-14 57 125 <10 107 81
3,000 2,000 1,000 0 1,000 2,000 3,000 4,000
HTS_TST_Male HTS_TST_Female
Among all populations who tested HIV positive, half were ages 30-49 and 20-34 among males and females respectively (Figure 7). As a result, starting in Q3, demand creation and more targeted testing will reach male and female beneficiaries aged 35-49, which resulted in a 6% and 4% case detection rate, respectively; the same age and sex distribution were reported among FC.
Figure 7. HTS_POS Age/Sex pyramid, All Populations, Q2 FY20
50+ 54 34 40-49 64 56 35-39 56 35 30-34 60 46 25-29 58 57 20-24 42 65 15-19 14 18 10-14 0 3 <10 2 3
80 60 40 20 0 20 40 60 80
HTS_TST_POS_Male HTS_TST_POS_Female
Among those who tested and received their test result, 667 (401 FC, 54 MSM, 3 TG, 9 FSW, 200 Other population) were newly diagnosed as HIV positive (3% yield), through the index and non-index testing. Most of the HIV positive beneficiaries were FC (60%) followed by Other populations (27%) (Figure 8). The latter shows the spill-over effect of the project in identifying additional HIV positive beneficiaries who are not from the primary target population and they are reached through index testing and self-referral to the facilities.
Figure 8. HTS_POS distribution by population category (n=667), Q2 FY20
When comparing the positivity rate between FC and non-FC, female FC reported a yield twice as high as the non-FC female (4% versus 2%, respectively) (Figure 9)
Figure 9. Tests and Testing Yield by Sex, All Populations, Q2 FY20 8000 4% 4% 7000 4% 4% 6000 3% 3% 5000 3% 4000 2% 3000 2% 2% 2000 1% 1000 1% 0 0% Male Female Male Female FC non-FC HTS_TST 7208 5519 3,764 7,304 HTS_POS 207 194 143 123 Yield 3% 4% 4% 2%
HTS_TST HTS_POS Yield
When comparing population groups, even though TG represents the category with the highest yield, this result is driven by the low absolute numbers; MSM (7%) followed by FC (3%) reported the next highest yield (Figure 10).
Figure 10. Yield by population, Q2 FY20
The fact that 1.5 times more beneficiaries were tested at facility level compared to the community level, was driven by the fact that half of the test were among non-FC who were self-referred to the facilities. However, the yield among FC tested at a health facility was twice as high as non-FC (Figure 11).
Figure 11. Yield by Testing Venue, All Populations, Q2 FY20 12,000 10,964 6% 9,745 10,000 5% 5%
8,000 4%
6,000 3% 3% 2% 3% 4,000 2,983 2%
2,000 1% 104 0 0% non-FC FC
Community HTS_TST Facility HTS_TST Community Yield Facility Yield
Within the community testing of FC, sub-grantee CSOs reported a yield ranging from 1% to 6%; highest yield (6%) was observed in Santo Domingo (SD) by ADOPLAFAM and Aid for AIDS (Figure 12), probably as a result of a higher degree of fidelity when rolling out EPOA as well as other more personalized testing approaches. CSO partners that have used more personalized approaches to community HTS have seen higher yield and higher ART initiation rates.
Figure 12. Community testing yield by CSO and geographic area, Q2 FY20
3,000 7% 6% 2,651 2,500 6% 6%
1,913 5% 2,000 1,687 4% 1,500 1,146 3% 3% 1,000 2% 2% 896 686 712 2% 2% 500 1% 1% 1% 74 54 3 43 63 16 29 9 8 - 0% ADOPLAFAM AID For AIDS CEPROSH IDEV (SD Nat REDOVIH (SD CEPROSH GRUPO BRA DOM (SD East) (SD) (Valverde) Distr) North) (Puerto Plata) CLARA (Monte Plata) (Puerto Plata)
Com HTS_TST index and non index FC Com HTS_POS index and non index FC Yield
At 29 HS3-supported sites, 33% (9) health facilities contributed 60% of new HIV positive FC. Yield analysis across sites showed a wide variability mostly driven by the absolute numbers which in some sites were particularly low, thus resulting in high yield (e.g. Yamasa 1/7=14%; and Yolanda Guzman Hospital 2/9=22%, both in Santo Domingo province); while other sites reported high yield and high testing volume (e.g. Bogaert: 17/94=18%, in Valverde province).
The comparison between the community and facility yield by province shows that in the same geographic area the yield at facility level is two to six times higher than at community level; this finding was observed also in Q1 and it might be driven by FC reaching the health facility only when they are ill. Valverde province reported the highest facility yield (7%) and contributed to identifying a third of all HIV positive FC (Figure 13).
As a result, the project will continue providing technical assistance to the CSO working in Valverde province to strengthen targeted testing within the community and the fidelity to EPOA. In addition, the project will explore options for creating demand in surrounding areas around supported health facilities within the province.
Figure 13. Community testing yield among FC by CSO and geographic area, Q2 FY20
1,400 1,222 8% 7% 1,200 7% 1,000 6% 6% 5% 800 5% 693 575 4% 600 3% 3% 3% 400 2% 1% 200 59 41 42 1% - 0% SD Puerto Plata Valverde
Fac HTS_TST index and non index Fac HTS_POS index and non index Fac Yield Com Yield
Index testing contributed 1% of the overall HTS_TST and 10% of the overall HTS_POS, ranging between 9% among FC and KP and 14% among other populations (Figure 14); 90% of the index testing was conducted at the facility level. In Q3 the project will enhance its support to CSOs aimed at increasing index testing efforts at the community level.
Figure 15. Index testing contribution to overall HTS and HTS_POS, Q2 FY20
14,000 16% 12,000 14% 14% 10,000 12% 10% 8,000 9% 9% 8% 6,000 6% 4,000 4% 2,000 1% 2% 1% 2% - 0% FC KP Other Pop FC KP Other Pop HTS_TST HTS_POS non index 12,545 1,401 9,505 363 60 173 index 183 29 133 38 6 27 % index 1% 2% 1% 9% 9% 14%
index non index % index
The following Figure 15 shows the index testing cascade among new HIV positive FC: among 401 FC index clients, 94% (377) were offered index testing, 51% (194) were eligible, 95% (184) accepted; 98% (176) of the elicited contacts (179) were reached with HTS, 23% (40) tested newly HIV positive, 98% (39) enrolled at ART clinic and 77% (30) started the treatment.
Figure 15. Index Testing Cascade among new FC, Facility and Community sites, Q2 FY20
450 94% 51% 95% 98% 23% 98% 77% 401 400 377 350 300 250 194 184 200 179 176 150 100 40 39 50 30 - New HIV New HIV New HIV New HIV Contacts Contacts New HIV New HIV New HIV POS FC POS FC POS FC POS FC reached received POS POS POS offered eligible accepted HTS Contacts Contacts Contacts index index index enrolled started testing testing testing in ART ART
Among those who were not eligible to receive index testing (Figure 16), between a third and half reported do not have any contact client; proportionally more FC weren’t ready to elicit their contacts (41% versus 9% among KP and other populations); many more KP reported IPV (39% versus 5-7% among FC and other
populations); between 17% and 28% had an HIV positive contact client and a small percentage (3-7%) reported that the contact was outside the country.
Figure 16. Ineligibility to Index Testing, by population Q2 FY20
100% 90% 17% 15% 28% 80% 7% 3% 5% 70% 5% 60% 39% 7% 9% 50% 41% 40% 9% 30% 51% 20% 31% 33% 10% 0% FC KP Other Pop
Do not have contacts Not ready to elicit contacts IPV Contact outside DR Contact already HIV POS
Overall, 70% of the FC index clients reported either do not have any contact or not feeling ready to refer the contacts, highlighting the need to strengthen the motivational interviewing aspect of the index testing counseling. In Q3 the project will roll out motivational counseling to providers and will continue supporting project clinical mentors that were deployed to directly offer this service starting March 2020. The project will also ensure that the index testing providers enquire and follow up on the already known HIV positive contact clients whether they are on treatment or not.
When comparing testing modality among FC, index testing continues reporting the highest yield at both the facility and community level (20-22%), while non-index testing yielded 5% and 2% at the facility and community level, respectively and EPOA reported 3% yield overall, at the community level (Figure 17).
Figure 17. Yield among FC by Testing Modality, Q2 FY20
12,000 25% 22% 10,000 20% 20% 8,000 15% 6,000 10% 4,000
2,000 5% 3% 5% 2% 0 0% Facility Community HTS TST non index 2,855 9,690 HTS TST index 128 55 EPOA 0 1,510 Yield non index 5% 2% Yield index 20% 22% Yield EPOA 0 3%
HTS TST non index HTS TST index EPOA Yield non index Yield index Yield EPOA
The project reached a 3% yield among FC through EPOA in each quarter, though in Q2 the project tested seven times more FC through this modality (Table 2). In Q2, the yield reached 9% at ADOPLAFAM supported community sites, though they reached a lower volume of clients when compared to other CSO who tested more FC, but didn't implement the service with enough fidelity and as result, their yield ranged between 1% and 3%. In Q2, ART initiation was high across all CSO.
Additional training and monitoring need to be implemented by HS3 to ensure EPOA is done at scale and with fidelity.
Table 2. Community-based EPOA to FC, Q1 versus Q2 by CSO CSO Q1 Q2 HTS HTS Yield TX ART Init HTS HTS Yield TX ART Init POS NEW rate POS NEW rate
Grupo Clara - - - - - 195 6 3% 6 100% Valverde CEPROSH Puerto - - - - - 206 2 1% 1 50% Plata CEPROSH - - - - - 181 3 2% - 0% Valverde IDEV Santo 51 1 2% 1 100% 484 15 3% 12 80% Domingo REDOVIH Santo 149 4 3% 3 75% 345 10 3% 9 90% Domingo ADOPLAFAM - - - - - 99 9 9% 8 89% Santo Doming total 200 5 3% 4 80% 1,510 45 3% 36 80%
The project also provided HTS to 1,510 OVC, diagnosing 16 HIV positive OVC (refer to section 3.4 Pillar 4).
Conclusions and Opportunities
● Acknowledging that index testing continues to represent a small proportion of the entire HIV testing. The project will continue working with health facilities and community partners to ensure that this service is included in the HTS standard of care, through supervision, mentoring, and training. ● Motivational interviewing will be rolled out to health care workers and peer navigators to support them during index testing counseling and refine their skills in explaining the rationale for such service. ● A mixed-testing approach will continue to be rolled out, with a focus on most effective testing modalities such as index testing and EPOA, as well as testing in communities after working hours; also consultations with the beneficiaries will take place to better characterize their needs and design service delivery modalities that meet their expectations. ● More efforts will be placed in reaching FC men at their workplaces and offering integrated HTS and ART. ● The experience of HS3 shows that the preferred modality of index testing is passive, which often implies that the identified partner does not arrive at the service, a situation that raises the need to implement contact from the provider. In Q2, HS3 developed a job aid for index testing providers (Annex 3) where clients are given a series of options for contacting partners, starting with the active provider-driven option, always ensuring the confidentiality of the index patient. ● The index patient should be offered that: 1) the provider calls the contact anonymously; if he/she refuses, then the next option is, 2) the index client to invite the partner to the site, but if he/she does not come within 7 days, then the provider contacts them anonymously. If this option is also rejected, then the provider will offer the last option 3) the index client brings the partners directly to the health center, the passive option. This job aid ensures that the active option is the first option offered and leads the conversation for the provider ensuring confidentiality and quality while discussing index testing with the index patient and while contacting the referred clients. In Q3, additional providers, including peer navigators, will be trained, and certified to provide index testing in both the facility and community. Additional training and practice sessions with providers are needed to scale up index testing and address gaps in the index testing cascade.
3.2 PRIORITY PILLAR 2: FC Community Approaches Strengthens Linkages
During FY20 Q2, at 16 HS3-supported health facilities offering ART service, a total of 428 beneficiaries (189 FC, 5 FSW, 39 MSM, 3 TG, 192 other populations) were initiated on ART among 667 diagnosed HIV positive in the same health facilities and in the linked-communities (64% ART initiation rate).
The disaggregation by males and females (Figures 18 and 19) shows a particularly low ART initiation rate among women ages 15-19 and 25-29 years, while the issue is involving a wider age range among men (15- 34 and 40-44) as well as males under 15. This finding reveals an important bottleneck on ART initiation among men as compared to women. As a result, in Q3 the project will engage in ad hoc consultations with men in the community to further understand barriers and enablers to ART. The project will also start developing messages that incorporate the men's perspective as well as offering dedicated community- based, men-friendly services after working hours where ART initiation is prioritized.
Figure 18. ART Initiation among Adult Women by age ranges, Q2 FY20
Figure 19. ART Initiation among Adult Men, Ages 15+, Q2 FY20
When disaggregated by population category, the ART initiation rate was higher among ages 45 and above, while ages 15-29 reported an ART initiation rate below 50% (Figure 20).
Figure 20. ART Initiation by age category, among All Populations, Q2 FY20 70 200% 180% 60 160% 50 140% 40 120% 100% 92% 30 80% 70% 76% 20 57% 59% 58% 60% 50% 47% 40% 10 36% 20% 0 0% < 15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
HTS_TST_POS TX_NEW ART Initiation Rate
When disaggregated by population group, younger ages reported the lowest ART initiation among FC, while ages 35-39 and 45-49 had the highest rates (Table 2).
As a result, in Q3 the project will roll out consultations and messages that specifically reach young adults FC, to better understand treatment bottlenecks in this age group and to increase treatment initiation rates. In addition, the project will explore options to engage elderly FC HIV positive on ART to mentor and sensitize younger newly diagnosed HIV positive FC on initiating ART.
Table 2. ART initiation by age group and by population, Q2 FY20
Age FC KP Other Pop ART Initiation ART Initiation ART Initiation HTS_POS TX_NEW HTS_POS TX_NEW HTS_POS TX_NEW Rate Rate Rate < 15 5 1 20% - - #DIV/0! 3 4 133% 15-19 16 4 25% 8 5 63% 8 7 88% 20-24 73 28 38% 11 4 36% 23 24 104% 25-29 76 33 43% 18 14 78% 21 16 76% 30-34 68 34 50% 15 15 100% 23 19 83% 35-39 62 40 65% 8 4 50% 21 22 105% 40-44 44 20 45% 4 4 100% 25 16 64% 45-49 21 14 67% 2 1 50% 24 26 108% 50+ 36 18 50% - - #DIV/0! 52 55 106%
Although in Q2 the ART initiation rate among FC increased when compared to Q1 (41% versus 30%), it remains a great challenge (Figure 21).
Figure 21. ART Initiation Rate by Population, Q2 FY20
ART Initiation among FC
During the reporting period, technical assistance was provided to sub-grantee CSOs to roll out alternative strategies to increase treatment initiation among FC, like evening testing and linkage and launching clinics offered by IDEV and Lotes y Servicios in partnership with REDOVIH, in Santo Domingo province. In the satellite clinic of IDEV, which began on January 7, of the 14 individuals diagnosed HIV+ during Q2, 13 of those initiated ART, representing an ART initiation rate of 92%. We do not have representative data for REDOVIH as they began in late February and were impacted by the COVID-19 crisis. Both centers were closed due to COVID-19 on March 19.
The low ART initiation rate among FC was driven by the fact that 61% of the HIV positive FC were identified at the community level, where HTS takes place after working hours when ART clinics are already closed, resulting in clients having to be navigated to the facility on the following day. Though some of the CSO- led facilities (e.g. IDEV and Lotes y Servicios) have implemented flexible ART clinics, this is not offered daily or at scale. The need to navigate the client’s days after HIV diagnosis negatively impacts ART initiation. In Q3 the project will continue engaging with the Ministry of Health to advance the community ART policy, as well as the remaining CSO-led facilities to scale up the provision of flexible ART clinics. Furthermore, requiring a chest X-ray prior ART initiation remains a practice across most of the facilities, which also results in increased risk to lose the client, who must return to the facility multiple times. In response, the project will scale up the Yolanda Guzman best practice of replacing the chest X-ray with a sputum test, which is more rapidly available and within the facility.
To address issues with ART initiation in Q2, the project rolled out a detailed ART incentivized support plan to improve ART initiation for all newly diagnosed FC. This includes nutritional support for the first three months (1,000 DOP per month), a phone card or phone minutes for one month to ensure constant
communication with peer navigators and providers (600 DOP), direct payment of complementary tests such as chest X-rays, as well as transportation to ART appointments for the first year. An analysis of the ART initiation rate among non-FC and FC, by network and geography, shows that the overall ART initiation rate is skewed by the low ART initiation rate among HIV positive FC who represent over half of the total HIV positive beneficiaries diagnosed and reported by the project. Certain networks and areas reported significant differences in ART initiation, like within the Ceprosh network in Valverde province and the Adoplafam network in Santo Domingo.
To address the lower ART initiation rate among FC, the project not only began to implement the ART incentivized package but also engaged in regular case management activities to trace the backlog of HIV positive beneficiaries not yet enrolled in ART. For example, from Q1 throughout Q2, HS3 traced HIV positive FC who were not started on ART; collect and discussed data weekly. Cases of clients lost over the holiday month of December were reopened and another round of tracing was implemented. Of the 362 FC not initiated on ART (Figure 22); 16% were enrolled in an HS3 ART site but not initiated on ART, 10% were initiated on ART in an ART site outside of the HS3 network, 12% left the country, 5% died, 13% refused services, 5% were still in counseling and 7% were still in tracing, 31% were not found after 3 phone calls and 3 home visits; only one person was detained by immigration.
Figure 22. The outcome of tracing HIV positive FC not enrolled into ART, January 1 to March 31 (n=362)
7% 10% Enrolled at non-supported ART clinic and 5% started ART Enrolled at non-supported ART clinic but not started ART Left DR 16% Dead
Refused
31% Detained by Imigration
12% Contact information available but not found
Not enrolled and on pre-ART counselling by navigator 5% No contact informaiton available 0% 13%
ART Initiation among KP
ART initiation among KP is further described and presented under the KPIF Section of this document.
ART Initiation among Other Populations
Among other populations, 95% was initiated on ART and they were virtually all from facility-based testing. Ages 25-29 and 40-44 reported the lowest initiation rate. The team will provide technical assistance to the supported facilities to ensure timely ART initiation with focus on the vulnerable age groups.
ART Distribution as part of the COVID19 Response
As part of the response to the COVID-19 pandemic, from mid-March 2020, in alignment with the national guidelines, the project identified all clients currently on treatment, classified them by stable and unstable clients and started contacting those who were due to receive an ARV refill within the following 60 days, so to bridge the period during which the country would have been locked down. As a result, 5,028 ART clients were estimated to have ARV refilled and were having accurate contact information to allow tracing; 1,322 were reached over a period of three weeks (Figure 23). Disaggregation by facility and community- based distribution was tracked only from April onwards and this data will be shared in the Q3 report.
Figure 23. Clients who were actively reached for ARV refill and number of sites, by week, Q2 FY20
Based on the national COVID-19 directives, the stable ART clients and those with good adherence who didn’t miss any appointment were supposed to receive 6-multi month dispensing (MMD), while all other categories, including ART naïve and returned to treatment were supposed to receive 3 to 5 MMD. However, an initial shortage of ARV possibly driven by the surge in active ART distribution in the whole country, resulted in still 13% of the client on average receiving 1-2 months supply; though on the last week of March, 20% of the clients received 3-5 MMD and 13% received 6-MMD (Figure 24). The distribution continued and intensified in April, once the ARV shortage was addressed and all sites rapidly started actively reaching the ART clients in the community (about 20-30%) and at the facility through staggered appointments (70-80%). At both venues, medications were distributed in compliance with social distancing and all the necessary infection prevention and control (IPC) measures.
Figure 24. ART Distribution by Supply, by week, Q2 FY20
Conclusions and Opportunities
● About 50% of clients not initiated on ART within one week are either not found, left the country, or refused services; the vast majority are from community testing. HS3 will explore with DIGECITSS if we can engage our clinical mentors or Gov ART clinicians to offer ART at the community level. ● Offer community ART; orient providers engaged in direct service delivery; pair the ART providers to the CSO-EPOA HTS team (Santo Domingo, Valverde, Puerto Plata) and with the CSO-workplaces HTS team (Valverde)
● Offer flexible ART clinics (flexy hours/days). Negotiate with NHS/SNS with the reopening of services to start doing it in selected sites offer incentivized ART package; continue offering incentivized ART package and continue tracing HIV pos not initiated on ART and intensify follow up. Significant efforts were done in Q2 to respond to the COVID-19 pandemic by actively contacting the ART clients and offering community-based ART distribution; a large volume of clients was reached within their communities or residences and others were served at the health facility through staggered appointments; the team was oriented on the standard operating procedures; infection prevention and control measures and social distancing were complied with at all times ● Even though in Q2 ART initiation among FC increased compared to Q1, it remains suboptimal and it is more broadly a gap affecting the male populations. As a result, the project will develop specific messages to reach these populations through social media; will rollout motivational interview training to health care providers and peer navigators through virtual platforms; will ensure that all ART clinics have a Creole-speaking peer available to support the ART clinicians and nurses with the language translation; and, lastly, in FY21, HS3 project will explore opportunities for engaging creole-speaking clinicians and nurses. ● The project hopes to see increases in ART initiation in Q3 with the rollout of the incentivized ART package as well as continuous support and contact by trained peer navigators. ● The tracing of HIV positive clients who did not start ART within the first week will continue as experience has shown this effort resulted in half of the lost clients being initiated on treatment.
● Additionally, the project will continue engaging with the sub-granted CSOs and with the health facilities to offer flexible ART clinics2.
3.2.2 Reaching Viral Load Suppression among All Populations
As of FY20 Q2, a total of 13,263 beneficiaries were currently on ART treatment (TX CURR) at 14 facilities. Among them, the large majority (78%) were from other populations and 12% were FC; 10% KP. Most of the clients were from Yolanda Guzman Hospital, followed by IDEV clinic and Clinica La Familia, which accounted for 54% of all clients currently on ART.
Among 142 clients who were returned to ART (TX RTT), 49% were from other populations and 42% KP; 9% FC. Most of the clients were from Bra Dominicana 5 Casas clinic, and IDEV clinic, which accounted for 78% of all clients returned to treatment; most of the FC clients returned to ART were from Bra Dominicana 5 Casas clinic. Overall, TX_RTT contribution to TX_CURR was equivalent to 1% on average, though reached 21% in the Bra Dominicana 5 casa clinic.
Overall, 3,672 clients did not have any clinical contact nor picked up ARV medications for more than 28 days since their last expected appointment (TX ML). Among them, 69% were other populations followed by 25% being FC; 6% KP. Most of the clients were from IDEV clinic, Yolanda Guzman, and Lotes y Servicio hospitals, which accounted for 64% of all clients lost to ART; most of the FC clients lost to ART were from CEPROSH clinic, Ricardo Limardo and Yolanda Guzman hospitals.
Detailed information is presented in Table 3.
Return to ART was led by the peer navigators’ efforts through a variety of approaches, depending on the situation; peer navigators traced the ART clients via phone calls, home visits and/or community investigation; the latter was conducted by enquiring through the peer network about the ART client who missed an appointment or was lost to follow up. In Q3 the project will put more effort into supporting those specific sites with a high proportion of lost to ART; focus will be placed to support the FC return to treatment.
2 Refers to ART services provided after working hours and/or during weekends
Table 3: TX_RTT by site, Q2 FY2
Site TX_CURR TX_RTT TX_ML TX CURR TX RTT TX ML TX TX ML TX RTT RTT contribution to TX CURR KP FC Other All Pop KP FC Other All KP FC Other All KP FC Other KP FC Other KP FC Other All All All Pop Pop Pop Pop Pop Pop Pop Pop Pop Pop Pop IDEV 667 144 1,601 2,412 49 - 6 55 206 28 561 795 28% 6% 66% 89% 0% 11% 26% 4% 71% 43% 22% 2% Ceprosh 147 367 1,036 1,550 - 1 3 4 - 195 234 429 9% 24% 67% 0% 25% 75% 0% 45% 55% 3% 12% 0% CLFR 178 250 1,650 2,078 - - -14 14 - 17 73 90 9% 12% 79% #DIV/0! #DIV/0! 100% 0% 19% 81% 0% 2% 0% Activo 20-30 29 23 615 667 2 - 13 15 1 10 90 101 4% 3% 92% 13% 0% 87% 1% 10% 89% 12% 3% 2% Hospital 79 184 1,063 1,326 1 1 1 3 - 68 277 345 6% 14% 80% 33% 33% 33% 0% 20% 80% 2% 9% 0% Lotes y Servicios Hospital 33 56 305 394 7 - 3 10 - 61 142 203 8% 14% 77% 70% 0% 30% 0% 30% 70% 8% 6% 3% Gonzalvo Hospital 76 157 539 772 - - - - - 109 150 259 10% 20% 70% #DIV/0! #DIV/0! #DIV/0! 0% 42% 58% 0% 7% 0% Limardo Hospital 45 127 2,454 2,626 - - - - - 51 566 617 2% 5% 93% #DIV/0! #DIV/0! #DIV/0! 0% 8% 92% 0% 17% 0% Yolanda Guzmán Hospital 39 152 387 578 - 2 1 3 - 216 208 424 7% 26% 67% 0% 67% 33% 0% 51% 49% 2% 12% 1% Bogaert Hospital 12 46 168 226 - 1 13 14 - 26 58 84 5% 20% 74% 0% 7% 93% 0% 31% 69% 11% 2% 6% Contreras Hospital de 6 12 121 139 - - 1 1 - 4 12 16 4% 9% 87% 0% 0% 100% 0% 25% 75% 1% 0% 1% Yamasa Hospital Los - 34 89 123 - - - - - 85 38 123 0% 28% 72% #DIV/0! #DIV/0! #DIV/0! 0% 69% 31% 0% 3% 0% Mina Hospital Boca 10 31 223 264 - - - - - 49 119 168 4% 12% 84% #DIV/0! #DIV/0! #DIV/0! 0% 29% 71% 0% 5% 0% Chica Bra 8 21 79 108 1 8 14 23 - 6 12 18 7% 19% 73% 4% 35% 61% 0% 33% 67% 18% 0% 21% Dominicana5 casa Total 1,329 1,604 10,330 13,263 60 13 69 142 207 925 2,540 3,672 10% 12% 78% 42% 9% 49% 6% 25% 69% 100% 100% 1%
Limitations to get permission to miss work and mobility issues, as FCs have expressed fear of deportation when traveling to access services, were also among the reasons for not returning to pick up the ARV refill. In Q2, immigration operations were reported in the vicinity of the SAIs in Puerto Plata, Valverde, and Santo Domingo, therefore limiting the flow of patients to those facilities.
Other situations identified by patients, such as access to food, transportation payment, and calling cards, were already addressed by HS3, which will contribute to improving adherence to medication collection.
An analysis of TX NET NEW was conducted across 14 health facilities for which the project reported TX CURR Q1 in FY20. As per PEPFAR guidance, TX NET NEW was calculated by subtracting TX CURR Q2 FY20 from TX CURR Q1 FY20. This analysis is presented in Table 4 below, illustrating a net overall gain of 372 clients. Overall, the total gain was mostly contributed by the new on treatment (75%) and the total loss by the lost to follow up (LTFU) and those who stopped the treatment (96%). If the total gain was mostly contributed by IDEV (25%), the same ART clinic also contributed to the largest loss (22%). Among all ART clients who were lost, 25% were FC; though this reached 69% in Los Minas, 51% in Bogaert, and 45% in Ceprosh. The former is mostly driven by migrant pregnant women who come to the Dominican Republic only to give birth and return to Haiti right after delivery. Further investigations will take place to explain the high loss in Bogaert Hospital and CEPROSH.
More broadly, other reasons for high rates of LTFU and low rates of TX RTT are the delayed data entry of the information into the electronic database (FAPPS), hence clients who returned to care are not accounted for; lack of case management service for non-FC clients as the project support tracing only FC who missed appointment and LTFU; inadequate supervision and monitoring of the peer navigators' efforts on tracing the FC who miss an appointment or are LTFU.
Please note that the project could not account for the number of transferred in (TI) as this is not a variable in the FAPPS.
In Q3 the project will continue engaging in discussions to expand the project case management support also to non-FC populations; will review the peer navigators’ efficiency with specific CSO like CEPROSH; will establish an M&E reporting system to monitor the outcome of the peer navigators’ tracing efforts.
Table 4. TX CURR and TX NET NEW by site, Q2 FY20
A B C=A-B D=C+G-K E F G=E+F H I J K=H+I+J L=G-K M N=M/K
TX NET Gain Loss HS3-supported ART TX_CURR TX_CURR adjusted Total Gain FC % FC No. TX NET LTFU and Total loss Facilities FY20 Q2 FY20 Q1 for TX_NEW TX_RTT gain dead Stop TO minus loss Loss Loss gain/loss treatment (652) 1 IDEV 2,412 2,380 32 88 55 143 0 785 10 795 28 4% (620) (380) 2 Ceprosh 1,550 1,544 6 45 4 49 1 426 2 429 195 45% (374) (20) 3 CFLR 2,078 2,051 27 56 14 70 1 2 87 90 17 19% 7 (66) 4 Activo 20-30 667 660 7 20 15 35 0 93 8 101 10 10% (59) Hospital Lotes y (277) 5 1,326 1,255 71 65 3 68 1 342 2 345 78 23% Servicios (206) (192) 6 Hospital Gonzalvo 394 358 36 1 10 11 0 200 3 203 61 30% (156) (230) 7 Hospital Limardo 772 742 30 29 0 29 1 258 0 259 109 42% (200) Hospital Yolanda (572) 8 2,626 2,528 98 45 0 45 0 617 0 617 51 8% Guzmán (474) (400) 9 Hospital Bogaert 578 496 82 21 3 24 0 424 0 424 216 51% (318) Bra Dominicana5 16 10 108 99 9 11 23 34 0 15 3 18 6 33% casa 25 (9) 11 Hospital de Yamasa 139 123 16 6 1 7 0 16 0 16 4 25% 7 Hospital Angel (57) 12 226 151 75 13 14 27 0 84 0 84 26 31% Contreras 18 (97) 13 Hospital Los Mina 123 120 3 26 0 26 0 121 2 123 85 69% (94) (166) 14 Hospital Boca Chica 264 299 -35 2 0 2 0 166 2 168 49 29% (201) (3,102) TOTAL 13,263 12,806 457 428 142 570 4 3,549 119 3,672 25% (2,645) 935
The Project also continued offering six multi months dispensing (MMD) and transition to Dolutegravir (DTG).
Based on SI USAID guidance, the DTG target was calculated for HS3 sites using as reference 70% of the clients currently on ART and in care (non-ART) as of the 1st of December 2019, hence clients already transitioned in Q4 of FY19 were excluded along with pregnant women and women in reproductive age (WRA) who were not on any family planning, as per national guidelines. The target does not include the anticipated new ART clients in FY20, as the project does not have a target for TX NEW for all populations; however, any new ART client is offered a DTG-based regimen as the first choice. In Q1 and Q2 the project did not disaggregate by new and already on ART, nor by population offered DTG-based regimen, however, will do so starting in Q3.
Cumulatively, as of the end of March, 38% of the target was met and 2,735 ART clients were successfully transitioned/initiate to the DTG-based regimen. Figure 25 shows the monthly progress and Table 5 shows the cumulative progress by site as of the end of March 2020.
Figure 25. ART clients who were transitioned to DTG-based regimen by month, FY20
1,400 1,314 1,200 1,000 914 800 600
400 288 220 200 - Oct-Dec 2019 Jan-20 Feb-20 Mar-20
Table 5. Cumulative Progress to DTG-based regimen Transition/initiation by site, as of March 2020
DTG-based regimen ART clients Progress to target Target started/transitione as of March 2021 d to DTG-based regimen, Progress as of March 2020 Santo YOLANDA GUZMAN 1,446 433 30% Domingo Santo IDEV 998 1277 128% Domingo Santo LOTES Y SERVICIOS 634 192 30% Domingo
Santo ACTIVO 20-30 318 89 28% Domingo Santo IDCP 302 9 3% Domingo Santo DE LOS MINA 88 39 44% Domingo Santo YAMASA 71 47 66% Domingo Santo BOCA CHICA 177 85 48% Domingo Monte Plata ANGEL CONTRERAS 130 42 32% Monte Plata BRA CINCO CASAS 60 34 57% Puerto Plata CEPROSH 817 121 15% Puerto Plata LIMARDO 447 101 23% VALVERDE BOGAERT 505 113 22% LA ROMANA CLF 1,007 114 11% LA ROMANA ANTONIO 274 39 14% GONZALVO
Total 7,274 2,735 38%
DTG clients also eligible for MMD were supplied three to six months of treatment. The annual 6-MMD target was set based on the national criteria for which only stable clients (VLS<1,000 copies) are eligible to receive such service. An important increase was reported in March when 268 ART clients received 6- MMD following the government directive to fast track such transition and expand it also to clients who were not virally suppressed but reported good adherence and attended all clinic appointments in the last 12 months (Figure 26). Data was not disaggregated by population in Q1 and Q2 as this is not a variable in the data collection form, however, from Q3 this information will be disaggregated and reported as well as disaggregated retroactively for Q1 and Q2.
Figure 26. ART clients who received 6-MMD by month, FY20
Among 11,754 currently on ART clients as of FY19 Q4 (all populations) at 9 ART facilities, 10,006 had a documented viral load test (85%) as of the end of March 2020. Five facilities are not included in this analysis because TX CURR Q4 FY19 data are not available. In addition, disaggregation by population was not possible because the data report was received, but not disaggregated by the implementing partner managing the previous project. However, from Q3 the analysis will be done and presented by population and for all ART facilities.
Viral Load coverage (VLC) among all ART clients was lower in Valverde and Puerto Plata provinces (25% and 62%, respectively) because following the stock out of VL reagents announced by the National Laboratory, the ART facilities in these provinces stopped prescribing the test; and it is higher in La Romana province because the ART facility in this province offered more robust client management and timely entry of the data into the national electronic database (FAPPS); also Santo Domingo province performed well reaching 92% VLC (Figure 27). The project is making a full review of the files of the clients who do not have a documented VL test result to understand and map out the gaps to develop a remediation plan.
Figure 27. Viral Load Coverage, by FC and non-FC, by Province, Q2 FY203
7,000 6,663 120%
6,000 101% 100% 92% 5,000 80% 4,000 62% 60% 3,000 2,217 2,344 40% 2,000 25% 1,000 530 20%
0 0% Santo Domingo Puerto Plata Valverde (Bogaert) La Romana (CLF, (IDEV, Activo 20- (Ceprosh, Limardo) Gonzalvo) 30, Lotes, Yolanda)
TX CURR Q4 FY19 %VLC
Note that in La Romana the coverage of TX-CURR with viral load in Q2, relative to TX-CURR which was 101%. The reason for this performance is due to the increase of the denominator (TX-CURR) between the two periods (11,754 and 13,263 respectively).
At the end of FY20 Q2, 10,549 beneficiaries currently on ART (all populations and all 14 ART facilities) had a documented HIV viral load result within the past 12 months, and 8,788 (83%) of them were suppressed (<1,000 copies/ml). About half of the sites (57%) reported between 80% and 90% VLS, while only one site reported over 90% VLS.
Table 5 describes the VLS by population: overall VLS was 84%, but as low as 75% among FC; 77% among FSW and TG (Table 6).
Table 6. VLS by population, Q2 FY204
Q2 FY20 FC FSW MSM TG Other Pop Total TX PLVS Den 828 184 486 74 8,977 10,549 TX PLVS Num 618 141 398 61 7,613 8,831 VLS 75% 77% 82% 82% 85% 84%
Santo Doming contributed 61% of all ART clients with suppressed viral load, among all populations. Viral load suppression rates ranged between 83% and 87% among non-FC and 67% and 100% among FC, though
3 Refers only to 9 sites for which TX CURR Q4 FY19 data report is available: IDEV, Ceprosh, CLF, Activo 20-30, Lotes, Gonzalvo, Limardo, Yolanda, Bogaert. The remaining 5 sites (Angel Contreras, Yamasa, Boca Chica, Los Mina, Bra Dominicana 5 casa) are excluded. 4 Color-coded VL coverage, and VLS refer to Red <80%; Yellow 80-89%; Green ≥90%
the rate is affected by the small absolute numbers (Figure 28). VLS in Valverde is difficult to interpret given the very low VL coverage. The project is making further data analysis and communicating with the ART clinics in Monte Plata to better understand and to address the VLS gaps, particularly among FC.
Figure 28. Viral Load Suppression Rate, by FC and non-FC, by Province, Q2 FY20
6,000 120% 5,107 5,000 100% 100% 85% 87% 83% 4,000 78%83% 80% 73% 73% 67% 3,000 60% 60%
2,000 1,725 40% 1,046 1,000 20% 244 119 1 110 29 182 225 0 0% Santo Puerto Plata Valverde Monte Plata La Romana Domingo
FC PVLS Num non-FC PVLS Num FC %VLS rate non-FC %VLS rate
The following Table 7 describes the actions that were taken to address low VL coverage and low VL suppression by site.
Table 7. Actions to address VL coverage (VLC) and VL suppression (VLS) by site, Q2 FY205
Province Site TX_ TX TX_ TX_ %VL %VLS (TX Action to increase VLC Action to increase VLS Priority CURR CURR PVLS Num Q2 PVLS Den Coverage (TX PLVS scale Q4 FY19 Q2 FY29 Q2 FY20 PLVS Den Q2 Num/TX FY20 FY20/TX PLVS Den CURR Q4 Q2 FY20) FY19) Santo Domingo IDEV 2,271 2,412 1,895 2,134 94% 89% - Develop a line list of non- medium VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test Santo Domingo Activo 20-30 630 667 460 552 88% 83% Develop a line list of clients Develop a line list of non- Medium eligible to VL but who VLS clients and contact haven’t received it yet, as them to assess ART well as verify data entry into adherence, mitigate the paper-based and barriers to adherence, electronic database (FAPPS) offer follow up test Santo Domingo Hospital 1247 1,326 965 1,169 94% 83% - Develop a line list of non- Medium Lotes y VLS clients and contact Servicios them to assess ART adherence, mitigate barriers to adherence, offer follow up test Santo Domingo Hospital 2,515 2,626 1,887 2,282 91% 83% - Develop a line list of non- Medium Yolanda VLS clients and contact Guzmán them to assess ART adherence, mitigate barriers to adherence, offer follow up test Santo Domingo Hospital de NA 139 98 121 NA 81% - Develop a line list of non- Medium Yamasa VLS clients and contact
5 VLC has been calculated only for 9 ART facilities for which TX CURR Q4 FY19 is available; Color-coded VL coverage and VLS refer to Red <80%; Yellow 80-89%; Green ≥90%
them to assess ART adherence, mitigate barriers to adherence, offer follow up test Santo Domingo Hospital Los NA 123 14 18 NA 78% - Develop a line list of non- High Mina VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test Santo Domingo Hospital Boca NA 264 130 180 NA 72% - Develop a line list of non- Very high Chica VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test Monte Plata Hospital Dr. NA 226 113 162 NA 70% - Develop a line list of non- Very high Angel VLS clients and contact Contreras them to assess ART adherence, mitigate barriers to adherence, offer follow up test Monte Plata Bra NA 108 43 62 NA 69% - Develop a line list of non- Very high Dominicana VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test Puerto Plata Ceprosh 1,505 1,550 658 726 48% 91% Develop a line list of clients - Very high eligible to VL but who haven’t received it yet, as well verify data entry into the paper-based and electronic database (FAPPS) Puerto Plata Hospital 712 772 507 643 90% 79% - Develop a line list of non- High Limardo VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test
Valverde Hospital 530 578 111 133 25% 83% Develop a line list of clients Develop a line list of non- Very Bogaert eligible to VL but who VLS clients and contact High haven’t received it yet, as them to assess ART well verify data entry into adherence, mitigate the paper-based and barriers to adherence, electronic database (FAPPS) offer follow up test La Romana CLF 1917 2,078 1,686 2,036 106% 83% - Develop a line list of non- Low VLS clients and contact them to assess ART adherence, mitigate barriers to adherence, offer follow up test La Romana Hospital 427 394 264 331 78% 80% Develop a line list of clients Develop a line list of non- High Gonzalvo eligible to VL but who VLS clients and contact haven’t received it yet, as them to assess ART well verify data entry into adherence, mitigate the paper-based and barriers to adherence, electronic database (FAPPS) offer follow up test Total 11,754 13,26 8,831 10,549 85% 84% 3
Conclusions and Opportunities
● The project made major progress in Q2 on the transition to/initiation of DTG-based regimen, as well rapidly scaled up the 6-MMD to ART stable clients and to those reporting high adherence, in response to the COVID-19 national directive. ● Overall, the project met the progress to TX CURR target, but important bottlenecks remain on VL coverage and VL suppression. ● The stock out of VL reagents during Q2 represented an important gap that drove the low VL coverage, while VLS needs continuous analysis at the site level to better understand issues around the quality of the ART adherence counseling and monitoring, the ratio between ART clients and peer navigators, specific populations' needs and understanding about VL test and VLS. ● ART clients who missed their clinic appointment or were lost to follow up were contacted by phone on the very same day of the missed appointment or the following day. However, it appears that this system might not be enough if not paired with close monitoring by the project on the full implementation of the case management service. From the other end, the project offered this service only to FC who overall represent only a quarter of the overall ART clients lost by the system, while the remainder are Dominicans for whom technical assistance was provided to the government ART providers at the facility level. Therefore, the project will focus on strengthening the FC case management and will prioritize sites that contributed the most to the loss, such as CEPROSH and Bogaert Hospital; efforts will be put to address factors that might discourage a client from returning to the service such as waiting time, the lack of clinics after working hours, the distance between the residence and the clinic. ● The high VL coverage rate reported in Santo Domingo and La Romana provinces might be explained by the proximity to the national laboratory, in comparison to other provinces. In Q3 the project will review the VL service and sample transportation system implemented in Puerto Plata and Valverde to identify challenges along the cascade; an ad hoc tool measuring the turnaround time (TAT) at each step and guiding a root cause analysis will be employed to improve VL coverage.
3.2.3 Tuberculosis Services to PLHIV
During FY20 Q2, a total of 77 beneficiaries (21 FC, 56 Other populations) active TB were initiated on TB treatment among 266 (63 FC, 192 Other populations) ART patients who were screened for TB at least once during the semiannual reporting period. This translates into a 2% screening rate and 29% TB case detection among those who received a screening (Table 8).
To address the particularly low TB screening rate, in Q3 the project will roll out ad hoc meetings with ART clinicians about the rationale for screening all ART clients, the national questionnaire and the TB-HIV collaborative activities; a mechanism will be established to frequently monitor the screening rate through the clinical mentors deployed to the sites.
Table 8. TX TB Cascade, Q2 FY20
Indicator KP FC Other Pop All Pop TX CURR 1,329 1,604 10,330 13,263 TX TB Den 11 63 192 266 %TX TB Den 1% 4% 2% 2% TX TB Num 0 21 56 77 %TX TB Num 0% 33% 29% 29%
During FY20 Q2, a total of 191 beneficiaries (30 FC, 7 KP, 154 other populations) complete on TPT among 326 (76 FC, 18 KP, 232 Other populations) ART patients who were initiated on TPT, during the semiannual reporting period (Table 9). Anecdotal stories from the sites reported a chronic shortage of isoniazid that might have impacted on the low completion rate of the prophylaxis. To address the low completion rate, in Q3 the project will work closely with GIS to assess the TPT stock, ensure facilities have enough supply of medications, and clients are closely supported to complete the preventive treatment.
Table 9. TB Prev Cascade, Q2 FY20
Indicator KP FC Other Pop All Pop TB_PREV Num 7 30 154 191 TB_PREV Den 18 76 232 326 %TPT Completion 39% 39% 66% 59% rate
3.2.4 Gender-Based Violence and Post Violence Care
In alignment with the PEPFAR minimum package, the project supported the provision of post-GBV clinical services, inclusive of rapid HIV testing with referral to care and treatment as appropriate, post-exposure prophylaxis (PEP) for HIV for individuals reached within the first 72 hours, STI screening and treatment, emergency contraception, for those who were reached in the first 120 hours. The project also supported screening and services for emotional and physical as well as economical violence. The providers were trained, and the M&E tools deployed to the field. Technical assistance was received from FHI360 headquarters by the gender senior technical advisor to support the rollout of a baseline assessment and the identification of the sites that were meeting minimum standards as well the development of a plan for the scale-up of the service at other sites. Overall, 272 post-GBV cases were reported (102 in Q2) and sexual violence represented 10% of all cases; lower than Q1 (17%) (Table 10).
Table 10. Reported post-GBV survivors, by site, by quarter, FY20 Q1 Q2 Physical/emotional Sexual Total Physical/emotional Sexual Total violence violence violence violence CLFR - 2 2 - 1 1 ACTIVO 20-30 10 13 23 1 3 4 LOTES Y SERVICIOS 2 - 2 - - - IDEV CLINICA 1 - 1 2 - 2 HOSPITAL LIMARDO 41 10 51 44 6 50 CEPROSH 66 - 66 42 - 42 CLINICA DE MUNOZ 20 5 25 3 - 3 Total 140 30 170 92 10 102
Conclusions and Opportunities
● The lack of integration between the TB and the HIV program represents a bottleneck to the collaborative activities; as a result, ART clients with presumptive TB are referred to the TB clinic and their TB treatment outcome is not regularly documented into the M&E tools of the HIV program. ● As a result, in Q3, the project will increase focus on strengthening the coordination and communication between the two vertical programs and will include in the project M&E system regular monitoring of the TB screening to the ART clients. ● The low coverage of preventive therapy with isoniazid is due to two basic causes: the shortage of the drug in some places, a situation that was resolved during the month of February, and on the other hand, problems with the recording of the data in the sites. Furthermore, the information is not reported in the FAPPS. HS3 is in the process of solving this situation by creating a daily monitoring form for the delivery of isoniazid, supporting providers to register the data in the patient's clinical record, and supporting the registration on the FAPPS platform, through the hiring of additional personnel.
2. PRIORITY PILLAR 3: Institutional reform to eliminate policy constraints
During Q2 of FY20, GIS continued the support interventions, focused on the national response to HIV and the PEPFAR strategy above site (central and regional level) and site level (facilities), including six components:
Component 1: Strengthen supply management system:
● Update of the Unified Pharmaceutical and Commodity Management System (SUGEMI, by the Spanish acronym) standard operational procedures (SOPs). Training of personnel is planned for Q3. Once trained personnel will be in a better position to implement reviewed tools and work routines to improve HVI pharmaceutical management.
● The transfer of ARV procurement to PROMESE/CAL. The transfer must be preceded by the approval of the International Procurement Unit by the Ministry of Public Administration (MAP, by the Spanish acronym). GIS had meetings with PROMESE/CAL and MAP to facilitate the approval. Additional information should be provided by PROMESE/CAL during Q3 for the approval clearance.
Component 2: Strengthen data quality and use of the logistic management information system
● Update SUGEMI electronic information tool. A protocol for a rapid assessment was developed in Q2. The collection and analysis of information, scheduled for Q3, will guide the update of the information tool, including features that will contribute to timely decision making.
Component 3: Transportation of laboratory samples and delivery of results
● Implementation of the Unified System for Transportation of Laboratory Samples and the Delivery of Results (SUTMER, by the Spanish acronym). During this quarter, GIS developed a protocol for conducting a baseline study that includes four electronic surveys to be completed by supervising implementers, laboratory authorities, and technicians at the national and regional levels. The results of the study, to be published and shared on Q3, will provide information to adjust the implementation of SUTMER to the operative conditions of PEPFAR supported facilities. The implementation of SUTMER will ensure the availability of viral load samples and results in time for decision-making and under the differentiated care model approved by the Ministry of Health for PEPFAR, therefore contributing to better documentation of improvements in the third ninety goal.
Component 4: Alternative mechanisms for HIV financing
No activities conducted in this component. This component will start in Q3.
Component 5: Other system strengthening interventions
● Support to the migration to DTG schemes and the introduction of MDD: GIS continued supporting the monitoring of the availability and consumption of ARVs and HIV commodities at central, regional facilities with PEPAR support. This information has been used to implement and measure the progress of the DTG and MDD strategy. Outlined in the DTG migration plan developed in the first quarter by the Ministry of Health and HS3 / GIS as a baseline and at the end of the second
quarter, 2,736 people with HIV have migrated to DTG schemes in health centers supported by HS3 (38% of that expected by the end of the fiscal year 2020 / October 2021).
During Q2, GIS also supported the development and issuing of MoH communications (Directrices) to provide guidance on emergency clinical and pharmaceutical management procedures during the COVID-19 pandemic. GIS supported the organization of an extraordinary delivery of ARV to regional warehouses and PEPFAR supported facilities to allow the implementation of MDD at the onset of the COVID-19 crisis.
GIS developed a supervision tool to identify the root causes of ARV stockout in PEPFAR supported facilities. By facilitating decisions on the site, this tool has contributed correct pharmaceutical management issues, preventing major stockouts.
● Preparation of health facilities for the provision of HIV services: GIS finalized the legal feasibility analysis for the accreditation of HIV services. Besides the standard requirements for the habilitation and extension of the provision of its services portfolio, GIS developed accreditation guidelines outlining all the requirements and bureaucratic steps to be completed. This document was validated by DIGECITTS and presented to FHI360, CDC, and USAID staff.
Component 6: Monitor, report, and participate in coordination meetings supporting key HSS.
● GIS developed an excel matrix and a dashboard in POWER BI® for monitoring the improvement in process and results in the indicators, compared with baseline indicators collected on Q1. These monitoring indicators include PEPFAR supply chain specific indicators (figure below).
● The submission of monthly reports to FHI360 on the availability of ARVs in the central warehouse, regional, and health facilities during the period January, February, and March 2020 continued.
3. PRIORITY PILLAR 4: OVC program to serve FC Families
The project also provided HTS to 25 OVC ACHIEVE beneficiaries, diagnosing 0 HIV positive OVC.
Strengthening coordination and clarifying roles and responsibilities were among the key themes discussed with the • ACHIEVE Project and the sub granted CSO which are working in both projects; importantly, HS3 made efforts to ensure that the existing peer navigators could support the additional workload o of the ACHIEVE Project for what concern the recruitment and o linkage to the ACHIEVE community workers. In Q2, HS3 arranged actions with HS3's ACHIEVE project, in o correspondence with the memorandum of understanding o signed in the first quarter of the year. This agreement has • allowed the identification of the beneficiaries of ACHIEVE in o the clinical sites supported by HS3, through navigators, as well o as the reference accompanied by the OVC to the clinical o services offered in these sites. Other coordination actions • o include the exchange of data, the joint review of tools, and the identification of opportunities for improved management of both projects.
To guarantee the quality of the data from M&E, the reported data was shared and presented to the partners; a process carried out through conferences and email with the corresponding teams. It is pertinent to clarify that the face-to-face validation process will be carried out once the current limitations of the pandemic have ended.
3.5 KEY POPULATION INVESTMENT FUND
For KP programming in the Dominican Republic, PEPFAR has allocated 1 million dollars from the Key Populations Investment Fund (KPIF) to be managed through the HS3 mechanism for a two-year period (FY20 and FY21). KPIF's goals align closely with HS3 and are intended to complement existing efforts to improve programs for KP. HS3 currently has sub-awards with three organizations under KPIF. Clinica de la Familia and Grupo Este Amor in the La Romana Province and Activo 20-30 in the Santo Domingo Province. Services are provided for KPs at the health facility level: IDEV and Activo 20-30 in Santo Domingo province, Clinica La Familia in La Romana province. Although only Grupo Este Amor is KP-led, Clinica de la Familia, Activo 20-30, and IDEV have over 20 years of experience working with KP and all have KP in leadership positions.
HIV Testing Services
During FY20 Q2, at 3 HS3-supported health facilities under KPIF, a total of 1,168 KP (504 FSW, 642 MSM, 22 TG) were tested for HIV (Table 11), through the index and non-index testing; index testing represented only 2% of the overall testing (29/1,160) following the PEPFAR moratorium that put on hold such service
starting from Q2. Among all tested, 5% (60) were diagnosed with HIV infection: this yield ranged between 2% at Clinical La Familia, 5% at Activo 20-30, and 19% at IDEV.
Table 11. HTS and Yield by population and site, Q2 FY20
HTS_TST HTS_POS FSW MSM FSW MSM TG KP FSW MSM TG TG Yield KP KP Yield Yield Yield IDEV 15 198 - 213 3 20% 36 19% - - 39 18% Activo 6 69 - 75 1 17% 3 4% - - 4 5% 20-30 CLFR 483 375 22 880 4 1% 10 3% 3 14% 17 2% Total 504 642 22 1,168 8 2% 49 8% 3 14% 60 5%
Clinica la Familia reported the lowest yield across all populations when compared to other sites, hence in Q2 HS3 conducted an analysis with the Clinica la Familia technical team on gaps and solutions related to low yield per population. To address these gaps the HS3 technical team has conducted a refresher training for key technical staff from Clinica la Familia in EPOA and increased funding for EPOA in the Clinica la Familia budget for Q3 and Q4.
ART Initiation
Among 60 HIV positive KP who were newly identified in Q2, 67% of them were initiated on ART, ranging between 56% at IDEV, 75% at Activo 20-30, and 88% at Clinica La Familia (Table 12). IDEV reported low ART initiation rates among both FSW and MSM, while the same was true for MSM only at Activo 20-30 and FSW only at Clinica la Familia.
Table 12. ART Initiation by population and site, Q2 FY20 Site HTS_POS TX_NEW FSW MSM TG ART KP ART FSW MSM TG KP FSW MSM TG KP ART Init ART Init Init Init IDEV 3 36 - 39 2 67% 20 56% - - 22 56% Activo 1 3 - 4 1 100% 2 67% - - 3 75% 20-30 CLFR 4 10 3 17 2 50% 10 100% 3 100% 15 88% Total 8 49 3 60 5 63% 32 65% 3 - 40 67%
In Q3, the project will be strengthening the technical assistance to the CSO and will invest efforts in developing a more personalized service to KP, to increase ART initiation rates which will include the comprehensive ART initiation package. Consultations will also take place with the beneficiaries to better understand barriers to treatment initiation and to identify strategies to mitigate them.
ART Retention and Viral Load Suppression
In Q2, 874 KP were currently on treatment at 3 supported ART clinics; the majority were MSM and most of the ART clients were receiving services at IDEV. Among the 207 who did not return to treatment (TX ML), virtually all were from IDEV and were mostly MSM; 51 returned to ART and again were mostly from IDEV and mostly MSM (Table 13).
Table 13. TX_CURR, TX_ML, TX_RTT, by population, Q2 FY20 Site TX CURR TX ML TX RTT FSW MSM TG KP FSW MSM TG KP FSW MSM TG KP IDEV 8 649 10 667 15 191 - 206 2 47 - 49 Activo 20-30 5 16 8 29 - 1 - 1 1 1 - 2 CLFR 42 119 17 178 ------Total 55 784 35 874 15 192 - 207 3 48 - 51
In Q3, more efforts will be placed in providing technical assistance to the CSO to invest more efforts in retaining HIV positive MSM into ART, and intensifying tracing efforts to return those lost in Q2.
Table 14 below shows the VL coverage by site and by population. Overall VL coverage was reported at 47%, driven by a 29% VL coverage in IDEV, while the other sites reported full coverage. VL coverage was low among MSM and TG.
Table 14. VL coverage, by population, Q2 FY20 Site TX CURR Q4 FY19 TX PLVSL Den FSW FSW VL MSM VL TG VL KP VL MSM TG KP FSW MSM TG KP coverage coverage coverage coverage IDEV 8 649 10 667 8 100% 181 28% 4 40% 193 29% Activo 5 16 8 29 5 100% 19 119% 2 25% 26 90% 20-30 CLFR 42 119 17 178 41 98% 130 109% 17 100% 188 106% Total 55 784 35 874 54 98% 330 42% 23 66% 407 47%
In Q3, the team will explore factors affecting VL coverage at IDEV and in particular populations, such as MSM and TG; clients’ file review will take place to assess documentation gaps; procedures for laboratory specimen collection and sample transportation will also be investigated.
Table 15 below shows the VLS by site and by population. Overall VLS was reported at 85: 85% VLS in Clinica la Familia, followed by Activo 20-30 (65%); while IDEV reported 91%. VLS in Activo 20-30 was as low as 60% among FSW.
So, in Q3, the team will focus on Activo 20-30 to assess the clinical files of the non-VLS FSW, discuss their ART adherence and ART regimen, plan for a follow-up VL test.
Table 15. VLS by population, Q2 FY20 Site TX PLVSL Num FSW MSM FSW MSM TG TG VLS KP KP VLS VLS VLS IDEV 7 88% 165 91% 4 100% 176 91% Activo 3 60% 14 74% - 0% 17 65% 20-30 CLFR 34 83% 111 85% 15 88% 160 85% Total 44 100% 290 58% 19 83% 353 85%
Tuberculosis Screening, Prevention and Treatment
None of the KP currently on ART received TB screening and none was initiated on TPT. This finding represents an urgent priority for which the HS3 team will identify a dedicated team to ensure all clients are screened and TPT is made available to those for whom active TB has been ruled out.
KPIF Program Management All KPIF partners participate in HS3 key training and receive tailored weekly monitoring and technical assistance meetings to review data and address gaps in programming.
In Q3 and Q4, HS3 is ensuring that all KPIF partners comply with REDCAP survey components to ensure high-quality index testing. This includes comprehensive GBV services through LIVES training as well as the collection of anonymous client feedback to not only report incidents but also make suggestions for improved KP programming.
In Q3, consultations will be held with KPIF partners and KP community members to plan for FY21 programmatic interventions.
Best Practices Part of KP programming has been to ensure that all high-risk negatives receive STI screening free of charge and additional HIV prevention counseling. IDEV has reported syphilis rates as high as 17% during routine STI testing. STI screening and treatment is provided free of charge through all KPIF clinical partners. Additionally, each organization funded under KPIF has a representative for each specific KP group; FSW, MSM, and TG.
3.6 RESPONSE TO COVID-19 PANDEMIC AND CHANGES TO THE COP 2019-2020 WORK PLAN
HS3 implemented quarantine measurements with its office staff starting March 19, 2020. In conjunction with HO technical support elaborated and submitted a contingency and continuity plan to USAID. The plan outlined risk reduction strategies for HS3 personnel and Civil Society Organizations (CSO) that implement interventions at healthcare facilities and communities and a communication strategy that promoted the use of virtual channels using different platforms such as Microsoft Teams, WhatsApp, SMS messages, Zoom video conference, Skype and Google HangOut chat. This plan also included the development of
Standard Operating Procedures (SOPs) to assure the continuation of ARV distribution during the COVID- 19 emergency. A virtual library was organized with all national directives and protocols developed by the MOH for COVID-19 affecting PLWHIV and technical norms and managerial procedures also developed/collected by FHI360 home office.
The following are some of the actions conducted on regular basis: ● Weekly webinar sessions with CSO implementing partners, MOH, NHS, and USAID including topics related to programming implementation challenges, best practices, and solutions, logistic issues, newly updated protocols, and guidelines. ● Daily epidemiological reports in Spanish and Creole shared with HS3 staff and CSO implementing partners ● Daily/weekly virtual meetings with different HS3 technical and administrative teams and ad-hoc meetings organized with CSO implementing partners and national counterparts.
Changes to the Work Plan 2019 - 2021
● As a result of the pandemic in the DR, HS3 submitted a proposal to USAID to reprogram USD$220,000 of PEPFAR funding to adapt HS3 programming within the context of COVID-19. In the work plan, HS3 prioritized the following actions: rapid ART initiation of newly enrolled HIV positive clients and refills for those currently on treatment; uninterrupted supply of ARVs to clients currently on treatment including those initiated during the pandemic; close clinical monitoring of non-virally suppressed ART clients; monitoring for uninterrupted availability PPE supplies; and, finally, rapid identification and isolation of HIV positive Covid-19 infected clients. ● Towards the end of March USAID invited HS3 to submit a work plan to manage USD$700,000 of emergency relief funds to provide additional support to PLHIV during the pandemic, in addition to HS3 activities. This incremental funding is expected in April. HS3 will work with our local partner GIS, in close coordination with the National Emergency Committee, MOH, NHS, Ministry of Economy, PAHO, and other cooperating partners. ● On March 26th, 2020, USAID notified HS3 that OHA had decided to pause weekly frequency reports, replacing them with a monthly report, until further notice. On March 30 HS# was notified that OHA also extended DATIM report submission to May 20, 2020.
3.7 ADDITIONAL ACCOMPLISHMENTS This section describes the key achievements in Q1 and Q2 on selected priority areas (Table 16).
Table 16. Key Achievements Priority Area Q2
Communication Social Media:
● The social network has grown remarkably in two months since being launched: Instagram developed a following of 281 users and Facebook 1,126. Digital efforts have had a reach of 788 initiated by the user, a paid reach of 21,168 users, and a general reach of 2,637 through both social networks.
● Social media content is focused on educational messages of HIV and sexual reproductive health, most of these messages have been translated to Creole.
● During the COVID-19 Pandemic, platforms have been used to send prevention guidelines and general information.
Emergency COVID-19 Pandemic Communication Strategy for Q3:
● Develop a plan to strengthen the communication network between stakeholders (partner organizations, administrative team, health care workers, navigators, and beneficiaries).
● Develop health care workers and peer navigator’s capacity to respond to HIV and COVID-19 cases.
● Guide clients through the HTS and ART services and provide ARV medication during the COVID-19 outbreak.
● Reduce PLHIV’s and FC/KP risk of exposure to COVID-19 and inform on how to access our COVID-19 services.
● Develop and launch a Hotline that offers a free communication space, to offer HIV services, psychosocial assistance (Gender violence, anxiety, etc.) and orientation and general information about HIV and COVID-19.
● As part of an e-health initiative, the project will develop a telemedicine strategy for consultations.
● Tele-navigation and tele-adherence will be provided through WhatsApp; telephone; SMS, to instruct the beneficiaries on how to access ART/TPT and TB TX/CPT, VL tests and at the same time follow up on their treatment.
Health Informatics • Participated in the meetings on the review of the national ART database (FAPPS) which have been coordinated by the SNS. The technical assistance focused on creating automated reports that address PEPFAR requirements. • Worked on the District Health Information System 2 (DHIS2) District Health Information Software 2 (DHIS2) which is an open-source health management data platform that HS3 will be using starting from Q4 of FY20 onwards. The DHIS2 will allow for automatic dashboards that aim at supporting decision-making processes on a daily, weekly, monthly, and quarterly basis. The dashboards will meet the data needs of the HS3 team working across different levels of the system from the site through provincial and national levels. The DHIS2 will possibly also allow importing data from aggregated sources such as FAPPS and other site-level sources.
3.8 MANAGEMENT AND OPERATIONS During this period four sub-awards were signed with a total amount of USD$477,751. The following table summarizes the organizations selected:
Table 17. New grants
Sub Awardee Amount
DOP USD
Alliance Heartland 2,493,985 47,532
Batey Relief Alliance 9,958,423 188,746
AID for AIDS Dominicana 4,837,336 92,200
Instituto Dermatologico y 7,950,379 149,273 Cirugia de la Piel
Total 25,240,123 477,751
During this quarter, one staff member was hired to support the use of vehicles to replace a deceased colleague. One program officer was hired to support Puerto Plata province and one more will be recruited for Santo Domingo in replacement of a colleague that resigned. Before the COVID-19 pandemic situation, the project struggled to hire five M&E officers and three clinical advisors. The challenge has increased with the pandemic but HS3 is looking for alternative ways to find this support. An unsuccessful local recruitment process was conducted to replace the Strategic Director (SI) that resigned in November 2019. A third-country national (TCN) was brought to the country to support the M&E team. Two international hirings are in process one for a Technical Director (TD) position approved in February 2020 and the SI Director. An advanced negotiation process is in place for the TD.
3.9 PRIORITY ACTIVITIES IN THE NEXT THREE MONTHS (Q3 FY20)
During the next three months HS3 will: ● Finalize the Emergency Relief Fund procurements in support the government (including clinical equipment, infection prevention, and control supplies,) ● Finalize the procurements included in COP 2019-2020 reprogrammed funds (including food support, provision of airtime and fuel support for transportation of ARVs, blood samples, lab results, and patients) ● Recruit for the vacant technical positions (Technical and SI Directors, M&E officers, and clinical mentors) ● Replace three clinical mentors that were promoted internally or resigned. ● Implement the COVID-19 hotline, telemedicine, and tele-navigation ● Review the distribution routes of navigators to release ART and increase the efficiency of the reduced number of navigators due to COVID-19 pandemic situation ● Exercise direct interventions with reluctant providers to increase 6-MMD
● Reduce the backlog of FAPSS reporting increasing the number of dedicated staff for data entry ● Support the rollout the training of CSO staff on gender-based violence with NHS leading the process ● Finalize the HIVST study design, budget, and develop the research protocol ● Review the re-opening process of HS3 office with USAID, MOH and FHI360 home office ● Prepare COP FY20-21 work plan
Annex 1. CSO-health facilities network implemented
Network in Q1 and Q2
Network from Q3
Annex 2. Progress by indicator and quarter
Q1 Q2 SAPR SAPR # Indicator FY20 progres number progress number progress % Target s of sites of sites progress to FY20 Target 1 PP_PREV_Comm_FC 63,503 - 14,341 5 14341 23% 2 HTS_TST non index_Facility_FC 20,116 3,183 25 2,855 26 6,038 30% 3 HTS_POS non index_Facility_FC 1,421 165 25 130 21 295 21% 4 HTS_TST non index_Comm_FC 51,267 7,332 4 9,690 7 17,022 33% 5 HTS_POS non index_Comm_FC 3,076 179 4 233 7 412 13% 6 HTS_TST non index_Facility_FSW 2,205 650 5 615 6 1,265 57% 7 HTS_POS non index_Facility_FSW 149 17 4 9 4 26 17% 8 HTS_TST non index_Facility_MSM 2,807 667 6 786 6 1,453 52% 9 HTS_POS non index_Facility_MSM 189 49 5 51 5 100 53% 10 HTS_TST index_Facility_All Pop 1,583 284 26 285 12 569 36% 10.1 HTS_TST index_Facility_FC 128 8 128 10 256 10.2 HTS_TST index_Facility_FSW 9 3 9 3 18 10.3 HTS_TST index_Facility_MSM 19 5 20 3 39 10.4 HTS_TST index_Facility_Other Pop 128 8 128 9 256 11 HTS_POS index_Facility_All Pop 317 74 7 58 11 132 42% 11.1 HTS_POS index_Facility_FC 33 4 26 8 59 11.2 HTS_POS index_Facility_FSW 3 3 - - 3 11.3 HTS_POS index_Facility_MSM 5 4 6 2 11 11.4 HTS_POS index_Facility_Other Pop 33 7 26 7 59 12 HTS_TST index_Comm_All Pop 2,768 32 2 60 5 92 3% 12.1 HTS_TST index_Comm_FC 31 2 55 5 86 12.2 HTS_TST index_Comm_FSW - - - - - 12.3 HTS_TST index_Comm_MSM - - - - - 12.4 HTS_TST index_Comm_Other Pop 1 2 5 1 6 13 HTS_POS index_Comm_All Pop 554 2 - 13 5 15 3% 13.1 HTS_POS index_Comm_FC 2 2 12 5 14 13.2 HTS_POS index_Comm_FSW - - - - - 13.3 HTS_POS index_Comm_MSM - - - - - 13.4 HTS_POS index_Comm_Other Pop - - 1 1 1 14 HTS POS TOTAL All Pop 486 - 494 980 14.1 HTS_POS_TOTAL_FC 362 - 401 - 763 14.2 HTS_POS_TOTAL_FSW 20 - 9 - 29 14.3 HTS_POS_TOTAL_MSM 54 - 57 - 111 14.4 HTS_POS_TOTAL_Other Pop 297 - 200 - 497 15 TX_NEW_All Pop 403 14 428 - 831 15.1 TX_NEW_FC 5,093 115 11 192 12 307 6%
15.2 TX_NEW_FSW 89 17 5 5 3 22 25% 15.3 TX_NEW_MSM 113 51 7 42 7 93 82% 15.4 TX_NEW_Other Pop 220 13 189 13 409 16 TX_CURR_All Pop 13,336 12,707 13 13,263 14 13,263 99% 16.1 TX_CURR_FC 1,455 13 1,604 14 1,604 16.2 TX_CURR_FSW 298 13 253 14 253 16.3 TX_CURR_MSM 915 13 1,076 14 1,076 16.4 TX_CURR_Other Pop 10,039 13 10,330 14 10,330 17 TX_ML_All Pop 3,240 13 3,672 14 3,672 17.1 TX_ML_FC 706 13 935 14 935 17.2 TX_ML_FSW - 4 15 4 15 17.3 TX_ML_MSM - 4 192 4 192 17.4 TX_ML_Other Pop 2,534 13 2,530 14 2,530 18 TX_RTT_All Pop 81 4 142 4 142 18.1 TX_RTT_FC 37 13 13 14 13 18.2 TX_RTT_FSW - 4 7 4 7 18.3 TX_RTT_MSM - 4 53 4 53 18.4 TX_RTT_Other Pop 44 13 69 14 69 19 TX_PLVS_Num_All Pop 10,811 9,161 13 8,831 14 8,831 82% 19.1 TX_PLVS_Num_FC 787 13 618 14 618 19.2 TX_PLVS_Num_FSW 180 4 141 4 141 19.3 TX_PLVS_Num_MSM 410 4 459 4 459 19.4 TX_PLVS_Num_Other Pop 7784 13 7,613 14 7,613 20 TX_PLVS_Den_All Pop 12,012 10,984 13 10,549 14 10,549 88% 20.1 TX_PLVS_Den_FC 1,086 4 828 4 828 20.2 TX_PLVS_Den_FSW 237 4 184 4 184 20.3 TX_PLVS_Den_MSM 491 4 560 4 560 20.4 TX_PLVS_Den_Other Pop 9,170 13 8,977 14 8,977 21 TX_TB_Den Already ART 10,660 - - 241 3 241 22 TX_TB_Den New ART 2,651 - - 25 2 25 23 TX_TB_POS Already ART 19 - - 52 2 52 24 TX_TB_POS New ART 53 - - 25 2 25 25 TB_PREV NUM 4,986 - 191 9 147 3% 26 TB_PREV DEN 5,538 - 326 6 326 27 GEND_GBV_Facility_All Pop 2,025 170 7 102 6 272 13%
Annex 3. Guidelines for Index Testing
si él / ella no viene dentro de 7 días, entonces el proveedor lo contacta anónimamente; si también se rechaza esta opción, entonces el proveedor debe ofrecer que 3) el cliente índice traiga a los socios directamente al centro de salud
2) Guía para ofrecer la prueba índice después de que el cliente sale VIH +
• Primer paso - terminar con la post consejería con el protocolo de la guía nacional para atención a personas VIH+ • Si una persona sale VIH positivo y el proveedor no ha colectado la información de sus parejas, hijos biológicos y amigos de riesgo, ANTES de la prueba hay que colectarla después de la prueba y no esperar hasta que la persona llegue al SAI. Si la persona no se siente lista es importante asegurar que el navegador le de seguimiento de la prueba índice con el cliente y tener información de contacto real.
• Guía para el Proveedor (que decir al cliente/paciente): • “Entendemos que divulgar su estado de VIH a sus parejas, hijos y/o amigos puede ser difícil; es por eso que podemos contactar de forma anónima a sus parejas sexuales, hijos biológicos y amigos de riesgo para ofrecerles la prueba del VIH.” • “Si sus parejas, hijos o amigos harán la prueba del VIH y salen positivos, entonces podrán recibir tratamiento contra el VIH para mantenerlos sanos y reducir el riesgo de transmitir el VIH a otras parejas sexuales y / o niños.” • “Si sus parejas tienen pruebas de VIH negativo, podrán acceder a los servicios de prevención del VIH para ayudarlos a seguir siendo VIH negativos, incluidos los condones y hacer la prueba cada 6 meses de forma gratuita.” • “Estos contactos no requieren que usted divulgue su estatus de VIH a las personas referidas; es anónimo toda la información es confidencial y no se compartirá ningún dato que divulgue su identidad” • “Generalmente, primero nos comunicamos con las personas referidas por teléfono; nos presentamos como proveedores del ministerio de salud que acceden a números de teléfono aleatorios para crear conciencia sobre los servicios de salud pública” • “Nunca mencionamos que obtuvimos su contacto a través de otra persona que le conoce” • “Hablamos sobre la importancia de recibir un chequeo médico y una prueba de VIH, entre otros” • “Ofrecemos el contacto para ser visitado en su lugar preferido en su comunidad y si él / ella se niega, le invitamos a ir al centro de salud más cercano”
Al paciente índice se le debe ofrecer primero que 1) el proveedor llama anónimamente al contacto; si él / ella se niega, entonces la siguiente opción es que 2) el cliente índice invite a las personas al sitio, pero si él / ella no viene dentro de 7 días, entonces el proveedor lo contacta anónimamente; si también se rechaza esta opción, entonces el proveedor debe ofrecer que 3) el cliente índice traiga a los socios directamente al centro de salud 3) Guía para contactar las personas referidas
Guía para el Proveedor (que decir a las personas referidas) A través de una llamada telefónica
• “Buen día. Mi nombre es (nombre usted mismo) y soy un proveedor de atención médica / consejero de HTS / navegador que trabaja con la organización (nombre de su organización) con el proyecto de HS3” • “¿Estoy hablando con (nombre de la pareja, amigo)?” • [Si dice No]: “¿Está disponible (nombre de la pareja, amigo_)?” • [Si la persona no está disponible]: “Gracias. Llamaré más tarde; amablemente hágale saber” • [En caso afirmativo]: “tengo información importante para usted. ¿Es ahora un buen momento para hablar?” • [Si dice No]: “¿Cuándo sería un mejor momento para que le llame?” • [Si la respuesta es SÍ]: “nos estamos comunicando con personas de la comunidad para explicarles que es importante aprender temprano sobre su estado de salud, para mantenerse saludables. Podemos ofrecerle detección de hipertensión, diabetes, masa corporal y la prueba de VIH • “Hoy en día el VIH puede tratarse con éxito, hay medicamentos que lo ayudan a mantenerse saludable y vivir una vida larga tanto como otras personas sin el virus; tales medicamentos tienen pocos efectos secundarios que se resuelven espontáneamente en pocas semanas. Si es VIH negativo, podemos brindarle información sobre cómo puede permanecer libre del VIH” • “No debe esperar para hacerse la prueba del VIH hasta que esté enfermo, porque para entonces los medicamentos serán menos eficaces” • “Podemos ir a su lugar preferido para ofrecer dichos servicios. Alternativamente, puede acceder a los servicios en nuestros sitios”