Zimbabwe HIV Care and Treatment (ZHCT) Project Quarter 3 Progress Report Year 1 : April 1, 2016 to June 30, 2016

Cooperative Agreement Number: AID-613-A-15-00009 Project Start and End Date: September 24, 2015 to September 24, 2020

Prepared for: Dr Ruth Bulaya-Tembo, AOR

Submitted by: Dr Kwame Essah, Chief of Party Family Health International (FHI 360) 65 Whitwell Road, Borrowdale West, Harare, Zimbabwe Tel: +263-8677 0042 18 Email: [email protected]

This report was prepared with funds provided by the U.S. Agency for International Development under Cooperative Agreement No. AID-613-A-15-00009. The contents of this report are the sole responsibility of Family Health International (FHI 360) and do not necessarily reflect the views of USAID or the United States Government.

Table of Contents

Table of Figures ...... 3 List of Tables ...... 3 List of Acronyms ...... 4 1. Executive Summary ...... 5 2. Introduction ...... 6 3. Detailed Activity Implementation Progress ...... 6 3.1 HIV Testing Services ...... 6 3.2 Symptom Screening ...... 13 3.3 Referrals and Retention in Care and Treatment ...... 13 3.4 Defaulter Tracking ...... 13 3.5 CARGs ...... 14 4. Summary ZHCT Achievements to Date ...... 15 5. Laboratory Services Strengthening ...... 16 6. Implementation Challenges ...... 16 7. Monitoring and Evaluation ...... 17 8. Collaboration with Other Stakeholders ...... 17 9. Administrative and Operational Issues ...... 18 10. Lessons Learnt ...... 19 11. Planned Activities for Q4 (July 1 to September 30, 2016) ...... 20 Annex I: ZHCT Annual Progress Summary ...... 21 Annex II: Overall Implementation Status ...... 23 Annex III: Success Story: Benefits of CARGS ...... 27

Table of Figures

Figure 1 ZHCT HIV Testing Cascade ...... 7 Figure 2: Number of individuals tested by age category and sex ...... 8 Figure 3: Clients testing HIV positive by district...... 8 Figure 4: Yield rate by district ...... 9 Figure 5 Linkage to care by District ...... 10 Figure 6: Linkage rate by age category ...... 10 Figure 7 Sources of index cases by entry point ...... 11 Figure 8 HIV services in DREAMs districts...... 11 Figure 9: HTS by month ...... 12 Figure 10 Cumulative District HTS against Annual Target ...... 12 Figure 11: Defaulters Tracking Cascade ...... 14 Figure 12: ZHCT project vehicles, motorbikes and bicycles// Photo Credits FHI 360 ...... 19

List of Tables

Table 1: TB Screening by Sex ...... 13 Table 2: Clients referred for different services after symptoms screening ...... 13 Table 3: Summary of Achievements ...... 15

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List of Acronyms

APHL Association of Public Health Laboritories AR&P Annual Review and Planning ART Antiretroviral Therapy AWP Annual Workplan CARG Community ART Refill Group CATS Community Adolescent Treatment Supporters CHO Community Health Officers COP Country Operational Plan CPF Community Program Facilitator DATIM Data for Accountability, Transparency and Impact DHIS2 District Health Information System DMO District Medical Officer FHI 360 Family Health International 360 GOZ Government of Zimbabwe HTS HIV Treatment Services LTFU Lost To Follow Up MOHCC Ministry of Health and Child Care MOU Memorandum of Understanding OPHID Organization for Public Health Interventions and Development PEPFAR President’s Emergency Plan for AIDS Relief PMD Provincial Medical Director PMP Performance Monitoring Plan PLHIV Persons Living with HIV PSI Population Services International SOP Standard Operating Procedures TBD To Be Determined UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development ZHCT Zimbabwe HIV Care and Treatment Project

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1. Executive Summary

This quarterly report is an outline and analysis of progress made towards achievement of annual targets during the period from April 1 to June 30, 2016 under the Zimbabwe HIV Care and Treatment (ZHCT) project. The reports highlights major results achieved as the project intensified implementation of HIV testing services activities initiated in the first two quarters in eight target districts in Manicaland and Midlands provinces. It also brings out critical lessons and challenges encountered during the period under review, while sharing effective strategies and approaches that will be intensified in Q4 as the project prepares for scale up in Year 2. As a comprehensive community-based intervention, data from the period under review shows that the ZHCT project is establish and maintain providing with sustained linkages for the target clients between the community and health facilities. In the first half of Year 1, the project was mainly focused on start-up activities as well as commencement of index case HIV testing. In this reporting period, the focus was on intensified provision of services ranging such as HIV testing and counselling and provision of results, enrolment in care and treatment, symptoms screening, defaulter tracking and tracing, as well as laboratory services strengthening support to the Ministry of Health and Child Care (MOHCC). The achievements in Q3 show that ZHCT project is well on course to surpassing most of the Year 1 targets (see Annex I: ZHCT Annual Progress Summary). The following bullets summarize the programmatic highlights during the period under review:-  10,258 individuals were tested for HIV and received their results against a quarterly target of 5,240, which reflects the intensified provision of HTS in Q3. Out of those tested, 640 (343 females and 287 males) tested HIV positive giving an overall yield of 6%. The majority (46%) of clients tested during this quarter were in the 25 – 49 year age group  As in Q2, Kwekwe district achieved the highest yield rate (8%) this quarter while Buhera district had the lowest (3.6%), even though the latter had a higher number of clients tested  Index cases from OI /ART points of entry, particularly Pre-ART registers, provided a higher yield rate (11%); followed by OPD (STI and VCT), which were both at 10% each. The index cases identified through outreach HIV testing gave the lowest yield rate of 4%  99% (2,096/2,123) of index cases identified accepted follow up CHOs, reflecting high acceptance of the index case testing approach in the target communities  The contractual processes of engaging Africaid will be finalized in Q4. Africaid specializes in HIV service provision for adolescents and young people through the Zvandiri model.  20 Community Health Officers (CHOs) underwent motorbike-riding training, and it is anticipated that HTS service provision will improve because of their increased mobility in the communities and access to hard to reach areas. In Q4, ZHCT will intensify targeting of sexual partners in the provision of HTS services while enhancing an expert-patient based active referral system to improve linkage to care. Other priority activities include strengthening lab services support and setting up of the DHIS2 database to strengthen data management in the ZHCT project. In preparation for scale-up to 14 additional districts in Y2, the inaugural joint ZHCT Annual Review and Planning (AR&P) meeting will be conducted on 5-7 July. The purpose of the three-day AR&P meeting was to undertake a strategic review of ZHCT project performance since inception and plan for Year 2 through a participatory process involving project staff, sub-recipient partners, and other key stakeholders. After the ARP, FHI 360 will commenced the process of drafting the Annual Workplan and Budget for the second year for submission to USAID by August 15th.

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2. Introduction This report covers activities implemented during the period April 1 to June 30, 2016 of Year 1 of the Zimbabwe HIV Care and Treatment (ZHCT), a five-year project funded by the United States Agency for International Development (USAID Zimbabwe), and implemented by Family Health International (FHI 360), the prime partner to USAID, and Plan International as a subawardee. The goal of the ZHCT project is to increase the availability and quality of care and treatment services for persons living with HIV (PLHIV), primarily through community-based interventions that complement the public health sector as part of the multi-sectoral response led by the Government of Zimbabwe (GOZ). The ZHCT project accomplishes this goal by meeting the following specific objectives:- 1) To increase the availability of quality comprehensive care and treatment services for HIV-positives at community level; and 2) To strengthen community-level health systems to monitor, track and retain persons living with HIV (PLHIV) in care. The ZHCT project has two main components: Component 1 focuses on expanding the provision of comprehensive care and treatment services. During the period under review, the priority in this component of the project was community-based household index testing, symptom screening and referrals. In Q4, focus will be on expanding some of the activities conducted in Q2 and Q3 and improving retention including defaulter tracking, ensuring completion of referrals and formation of CARGs (see Success Story on CARGs in Annex 111). Component 2 of the project focuses on improving HIV treatment support systems in the targeted communities. 3. Detailed Activity Implementation Progress This section presents a summary of the key highlights from the ZHCT project for the period April 1 to June 30, 2016.

3.1 HIV Testing Services

10,258 clients were tested; counselled and received their results during the period under review, with an approximate equal number of males and females (5,133 and 5,125 respectively) (see Figure 1 below). Out of these clients 97% (9,969/10,258) were tested through index case testing while the remainder was through outreach activities. The overall yield rate through index case testing was 6% while outreach activities had 4%. A review of Q3 data shows that other household members are being tested other than the sexual partners or immediate family members, which could account for the relatively low yield rates. In Q4, the project has set a target of testing at least 60% of the sexual partners, which is expected to improve the yield rate. This will be achieved through flexible working hours including testing during weekends to enable more potential clients who are otherwise inaccessible during the working week to be reached.

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Figure 1 ZHCT HIV Testing Cascade

As shown in Figure 2 below, most of the clients tested (46%) were aged 25 – 49 years. This was a similar trend as reported in Q2, and is consistent with national level HTS data. Among this age group, more men (52%) were tested for HIV and received their results which is slightly higher than the national average. These results suggest that the household index testing approach may improve the coverage of HIV testing for men going forward.

Of all clients tested, 86% were aged 15 – 49 years, highlighting the deliberate effort by the project to reach out to the sexually active age group. It should, however, be noted that the project continued to encounter challenges in reaching out to specific age groups such as adolescents (10 – 19 years) and young people (20 – 24 years) as their total contribution remained low in Q3. This was due to inadequate mobilization and targeting of these specific age groups, which we plan to improve on in the coming quarter. Through the anticipated engagement of Africaid as a sub-recipient, ZHCT expects to reach out to greater numbers of clients in these age groups. Africaid has documented technical expertise and experience in reaching out to adolescents and young women through their successful tried-and-tested Zvandiri model.

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5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 <1 yr 1-4yrs 5-9yrs 10-14yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+yrs

Male Female

Figure 2: Number of individuals tested by age category and sex

Although an approximately equal number of males and females were tested for HIV as shown above in Figures 1 and 2, 45.6% (287/630) males were HIV positive. Among these, 12% (35/287) were aged 10-24 years, while about 30% (101/343) of females aged 10-24 years contributed to the overall 55% of females who tested positive. This is consistent with other national and project data showing high prevalence among adolescents and young women reinforcing the importance of the DREAMS initiative. In addition, it also suggests the greater exposure of women to HIV due to socio-economic challenges in the country. Overall, 63% of the clients who tested positive were aged 25-49 years.

Figure 3: Clients testing HIV positive by district

Figure 3 above shows that more male clients were reached with HTS in Kwekwe, Mutare and Buhera districts. In both Buhera and Kwekwe, the active involvement of male Outreach Workers who also constitute a considerable proportion in the two districts, helped in engaging more men. In Kwekwe district, the teams have started implementing flexible working hours, which accommodates the busy schedules of male clients. Additionally, targeting of index cases who reside around informal mines, farming areas and growth points especially women resulted in more male clients reached with HTS.

Kwekwe district recorded the highest yield rate (8% [132/1,669]) during the period under review; while Buhera district had the lowest at 3.6% (51/1,415) a similar trend to Q2 results (see Figure 4 below).

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Kwekwe’s trend could be due to the reasons highlighted above. Buhera’s situation is unique due to the greater number of HIV programs which have been operational in this district in the previous years, particularly through MSF. Based on the current yield rate and the targets for FY17, the project will gradually scale down household testing in Buhera district and focus more on Component 2 activities.

Kwekwe

Chipinge

Gokwe South

Gweru

Makoni

Mutare

Mutasa

Buhera

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%

Figure 4: Yield rate by district

The project has noticed a number of challenges in linkage to care such as patient mobility, non-disclosure, a preference for facilities outside catchment areas, user fees in some health facilities, as well as unavailability of clients due to work commitments, particularly in farming communities. Among the clients who tested HIV positive, 45% were linked to care as shown in Figure 1 above (ZHCT HIV Testing Cascade). This lower-than-targeted linkage rate is an area of concern in the project as it is based on documented evidence of linkages, e.g registration of clients in Pre-ART register or availability of a completed referral slip at the facility. It is anticipated that the orientation and capacitation of Outreach Workers with mobile phone and bicycles will facilitate active referral and tracking of clients. It should be noted that, despite the challenges noted above, the number of clients linked to care have increased seven-folds in this quarter compared to the previous quarter, and we anticipate further improvements going forward. Overall, Makoni had the highest linkage rate while Kwekwe had the lowest as shown below. The low linkage rate in Kwekwe is due to the high mobility and work commitments of the artisanal miners and farmers. As for Makoni, each CHO closely works with their respective Outreach Workers so that all those who test positive are enrolled into care. On a weekly basis, a day is set aside for such active follow-up of clients who were referred from the previous week. This approach will be replicated in other districts to improve linkage to care across the two provinces.

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Linkage Rate By District 140 100% 120 90% 80% 100 70% 80 60% 50% 60 40% 40 30% 20% 20 10% 0 0% Gokwe Buhera Mutasa Mutare Makoni Gweru Chipinge Kwekwe South Diagnosed 51 29 68 70 81 118 81 132 Linked to Care 14 15 40 66 32 63 34 22 Linkage Rate 27% 52% 59% 94% 40% 53% 42% 17%

Diagnosed Linked to Care Linkage Rate

Figure 5 Linkage to care by District

The linkage rate for those below 15 years was higher at 89% (33/37) compared to those aged 20-24 years [38% (34/90)] as shown in Figure 5 below. This is due to the parental support. Generally, clients that are sexually and economically active (15-49 years) had challenges in being linked to care. This poses a huge challenge in curbing HIV transmission in the communities and more effort (e.g active referral) will be done to ensure clients are quickly enrolled into care.

600 100%

89% 90% 500 80% 70% 400 60% 53% 300 50% 50% 41% 38% 40% 200 30% 20% 100 10% 0 0% <15 yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+yrs

Diagnonised Linked to care Linked Rate

Figure 6: Linkage rate by age category

Overall, the proportion of clients tested to the yield by point of entry highlights that higher yields are among index cases identified from the OI/ART registers, particularly Pre-ART, while the lowest are from the outreach activities. In Q4, ZHCT Community Health Officers will prioritize identifying more index cases from Pre-Art registers and out-patient departments to improve the overall yield rate. 99%

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(2,096/2,123) of index cases identified accepted follow up visits, reflecting high acceptance of the index case testing approach in target communities.

Figure 7 Sources of index cases by entry point

The yield rate in the DREAMs districts was generally low (0-3%) among males aged 15-19 years. The yield rate among females aged 15-19 years was highest (12%) in Gweru as shown in Figure 8 below. Among those aged 20-24 years, the yield rate was much higher among females compared to their male counterparts except in Makoni. This highlights how vulnerable young female are in these districts.

Figure 8 HIV services in DREAMs districts. 11

Overall, although the yield rate dropped in May 2016, the number of clients tested every month increased compared with the previous reporting period. To date, ZHCT project has managed to surpass its annual target in half of the target districts as shown below in Figure 8. In summary, the project will implement strategies highlighted above to improve the yield rate such as targeting of sexual partners and immediate family members, hotspot mapping, testing outside working hours as well as flexible working hours by ZHCT staff.

4500 8.0%

4000 6.9% 7.0% 6.4% 3500 6.0% 3000 5.5% 5.0% 2500 4.0% 2000 3.0% 1500 1000 2.0% 500 1.0% 0 0.0% April-16 May-16 June-16 1964 4032 4262 136 223 271 Yield Rate 6.9% 5.5% 6.4%

Figure 9: HTS by month

Figure 10 Cumulative District HTS against Annual Target

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3.2 Symptom Screening

All HIV positive clients are screened for other communicable and non-communicable conditions, with a deliberate aim of screening all newly diagnosed PLHIV for TB as shown below in Table 1. The provision of symptom screening as part of a comprehensive package of services helps reduce the stigma and discrimination associated with HIV as every client undergoes some type of screening.

Table 1: TB Screening by Sex TB Screening Male Female Total Tested 5,133 5,125 10,258 Positive 287 343 630 Screened for TB 287 343 630

3.3 Referrals and Retention in Care and Treatment

Table 2 below highlights clients referred to facilities for different services after symptom screening. The referral completion rate is very low in most cases as shown below. Some of the reasons include clients preference for health facilities outside the ZHCT catchment area, no documented evidence of completed referral at health facility and the fact that Outreach Workers were capacitated (bicycles and phones) in June which limited their mobility and ability to do follow ups. In Makoni district, use-fees have also been reported as an impediment to referral completion. ZHCT will continue to work with facilities and communities to improve this as the spill-over effect will improve referrals for those newly diagnosed PLHIV.

Table 2: Clients referred for different services after symptoms screening Clients Successfully Completion Services Referred Referred Referred Rate Diabetes Mellitus 11 1 9% Hypertension 89 23 26% TB management 250 102 41% Family Planning 43 13 30% VMMC 118 14 12% Other 548 174 32%

3.4 Defaulter Tracking

359 defaulters were successfully returned to care as shown in Figure 10 below. Out of the 1,215 clients who were registered within health facilities, 78% were tracked and out of these 72% were identified. However, more than a quarter (28% [188/680]) of the clients identified were confirmed to still be in care. These findings suggest that the annual target figure proposed by the project for defaulters in Year 1 was over-estimated owing to poor documentation at facility level. The linkage to care of true defaulters was approximately 73% (359/492) which was a good achievement. The project will ensure that all registered defaulters at facilities are tracked and their outcome determined. In addition, the ZHCT staff will work with facilities to update registers such as appointment, Pre-ART and ART registers. This will allow Outreach Workers to use resources efficiently by tracking true defaulters.

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Figure 11: Defaulters Tracking Cascade

3.5 CARGs

241 CARGs were formed and capacitated, surpassing the annual target of 100. The CARGs supported during the period under review have a total membership of 2,290 with an average number of 10 individuals per group. Out of all the CARGs formed and capacitated, 1,461 PLHIV have started receiving ARVs at community level, constituting 64% of the total membership.

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4. Summary ZHCT Achievements to Date The table below summarizes the project’s achievements in delivering services to clients during the period under review. The green colour indicates that the ZHCT project managed to achieve the set quarterly targets; yellow indicates that the project performed above average but did not achieve the set targets, while red represents a below average in the achievement of set targets. Table 3: Summary of Achievements

Quarterly Achievements Targets (April – June 2016) Deliverable Indicator Annual Quarterly Targets Targets Male Female Total % (Sep 15 – (April – Sep 16) June 16) Number of individuals who receive HIV Testing and Number of individuals tested for Counselling (HTC) services for HIV and received their test HIV and received results 11,582 5,240 5,133 5,125 10,258 196% results % of clients testing HIV+ during reporting period Number of individuals diagnosed 10% 10% N=287 N=343 6% 6% with HIV % of new PLHIV who were screened for TB symptoms at Number of clients screened for the community level during reporting period TB symptoms 90% 90% (472) N=287 N=343 100% 100%

% of new PLHIV who are successfully linked to care during Number of clients successfully 70% 70% N=125 N=161 45% 45% reporting period linked to care % of clients with completed referral to the health facility for Number of clients referred 70% 70% 259 501 760 47% health services Number of HIV+ adults and children newly enrolled in Number of clients enrolled in 811 367 125 161 286 78% clinical care (pre-ART) during the reporting period clinical care Number of individuals trained in one or all of the following: Number of individuals trained HIV Testing; HIV Care; HIV Treatment; GBV during the 248 105 469 924 1,393 1327% reporting period Proportion of ART defaulter clients tracked and successfully ART defaulter clients tracked and 80% 80% 73% 73% returned to care during the reporting period linked back to care Number of CARGs formed or identified and capacitated on CARGs formed 100 42 242 242% community HIV services provision within a reporting period Number of PLHIV receiving ARVs at the community level PLHIV receiving ARVs through refill groups during refill groups during the report 960 480 512 949 1,461 304% period Proportion of clients successfully linked to care for viral Number of clients with viral load load testing from the community during the reporting tests done after referral B+5%1 TBD [N=246/402] 61% 61% period

1 B is the baseline to be determined. 15

5. Laboratory Services Strengthening In June the Senior Technical Advisor for Labs and Logistics commenced work to support with strengthening HTS quality assurance as well as other laboratory services strengthening activities. Recruitment processes for two laboratory scientists and one data entry clerk for Mutare Provincial Laboratory and Gweru Provincial Laboratory have started with anticipation that they will assume duty in Q4. The procurement for viral load ancillary equipment and consumables started at the end of June and will be completed in Q4. The procurement of viral load reagents and request for approval to procure restricted commodities from USAID is in progress and is anticipated to be completed in Q4. The project continues to collaborate with the Association of Public Health Laboratories (APHL) to coordinate the division of responsibilities between APHL and FHI 360. 6. Implementation Challenges The following are the major implementation challenges encountered during the period under review:-

 Stock-outs of rapid HIV test kits at facility-level: Both provinces experienced stock ruptures of HIV rapid test kits during Q3. This was as a result of the shortage at national level owing to delays in the delivery of the expected shipments. To avert interruptions in service delivery within the ZHCT district teams mobilized these test kits from the other facilities.

 Low uptake of HTS among male sexual partners of female index cases: To enhance our targeting to particularly reach out to male sexual partners of the index case going forward the ZHCT will consider more innovative approaches for the men who are usually at work during the time household visits are conducted e.g. establishing HTS within work places, testing after hours. The HTS register has also been revised to allow for better analysis of the yield across the different target groups.

 Poor documentation in facility registers affecting tracing and tracking of defaulters: Engaging Outreach Workers, who among other things will support with updating the facility appointment diary, there should be a huge improvement in tracing and tracking of defaulters.

 Transport challenges: Despite having procured 11 vehicles and 30 motorbikes for the project, training of CHOs in riding a motorbike was delayed due to trainers’ prior commitments. This resulted in reliance on the district vehicle. However, considering that in our approach, testing is conducted at household level, mobility within the teams was limited as the team members could not visit different areas simultaneously. Going forward, this is set to improve following the training and certification of the majority of CHOs in motorbike riding.

 Updating and retrieval of referral slips at facility level: This continues to be a challenge at some facilities especially the district hospitals where the relevant facility staff cite heavy workloads as the cause for not filling the tear off slips. Resultantly, slips end up not getting filled and referrals are lost along the way. The district team have been urged to adopt a rigorous follow up protocol/mechanism in order to ensure that referrals are complete.

 Limited access to viral load services: Access to viral load remains limited in both provinces, which continue to implement targeted viral load. This is further worsened by challenges in sample transportation. In Q4 ZHCT will focus more on lab services strengthening in partnership with other stakeholders.

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 Disposal of waste: There are no incinerators at 22 primary health facilities especially in Midlands where CHOs have to resort to transporting waste to district facilities for disposal posing a health risk. In Q4, the ZHCT will support construction of incinerators at these facilities to allow for appropriate waste disposal in line with ZHCT Environmental Mining and Mitigation Plan. 7. Monitoring and Evaluation The ZHCT M&E unit coordinated the compilation and analysis of project data from Midlands and Manicaland for the period under review. The unit further provided weekly reports through a performance dashboard and for project monitoring. In addition, the team provided an interpretation of the weekly performance to the district teams and also outlined key action points for teams to address gaps and also consolidate successes. The following were the main activities implemented:  Database Systems: The team managed to review the existing data management systems and the DHIS2 platform was selected. A consultant with experience in setting up the DHIS2 has been engaged and will be working on installation, customization and training of users in the next quarter. The platform will manage both aggregate and patient-level data. The project has continued to make use of the performance dashboard to provide near-real time data to inform programming. A total of 245 mobile devices were distributed to project staff in the field to assist mainly with implementation of activities such as defaulter tracking, linkage to care and other project-related communication requirements.  Data Collection Tools: Two DCTs were revised during this implementation phase to ensure appropriate data was collected by incorporating the comments from the project district teams and other key stakeholders.  Technical Support and Supervision: During the period under review, two technical support and supervision visits were conducted in the Midlands and Manicaland. These visits mainly focused on verifying and validating data using the Data Verification and Improvement Tool (DVIT). It was noted that the district teams have generally improved in their appreciation of all the different Data Collection Tools (DCTs) and the indicators. However, the teams will continue to work with the Monitoring and Evaluation Assistants so that all field teams have a good appreciation of the project’s data elements.  Quarterly Data Review: The two provinces conducted quarterly data review meetings to review and interrogate data so as improve programming and also inform progress. Part of the review meetings also focused on service availability and what have the project managed to achieve within the targeted districts and also considering the opportunities and challenges faced. Overall, the meetings provided a platform for district teams and the technical team to discuss the project activities, identify areas that require strengthening and sharing of experiences within districts.  Baseline Assessment and Mapping Exercise: During the reporting period, the team facilitated the training of the data collectors who assisted in the data collection in all the eight districts. Key components of the training were obtaining consent, data collection and management. Baseline Assessment and Mapping Exercise was done in 126 health facilities in the two provinces and this focused on 18 selected indicators for data collected in twelve months of 2015. Key informant interviews were held with representatives from the MoHCC, NAC, NGOs and community leadership. The process of data entry, analysis of the data, compilation and dissemination of the report will be completed in Q4. 8. Collaboration with Other Stakeholders The ZHCT project continues to collaborate and engagement with key stakeholders at national, provincial and districts levels. During Q4, project team members actively participated in the 2015 HIV Care and Treatment guideline adaptation through involvement in all adaptation committees as well the national stakeholder consultative meetings. The adaptation process provided an important platform to advocate 17

for some recommendations such as the role of lay testers at community level among others. The technical team also participated in the revision of the National HIV Testing Strategy, the Test and Start Technical Working Groups, weekly coordination meetings within AIDS &TB programs, Partnership Fora (PMTCT, HIV Prevention, TB/HIV) and Quality Assurance Costing stakeholders meeting. Several technical working groups were convened during this quarter (e.g Viral Load and M&E) and ZHCT actively participated in these meetings. PEPFAR Clinical Cascade and DREAMS partners meeting were also convened under the PEPFAR coordination and these provided critical platforms for ZHCT to interact and coordinate with other implementing partners. Regular coordination meetings with OPHID Trust to discuss collaboration at site level continued culminating in the drafting of an MOU by the two parties which provides an overall framework for enhanced collaboration at district, provincial and national levels.

In Manicaland province, ZHCT project staff has been part of both provincial and district health team meetings as they present progress of the index case testing approach. The provincial and district health stakeholders appreciate the household testing by ZHCT project as well as critical gap in community-health facility linkages that the project is covering. FHI360 was also part of the provincial and district level partners invited by MOHCC to discuss strategies to increase active case detection to both adults and children. Within the project, CHOs are encouraged to take TB samples on spot and submit to the health facilities or refer the clients for sample collection so as to improve case detection. Manicaland is piloting active TB case detection, therefore every patient who tests positive should be referred for TB investigation.

Nurses meeting at district level// Photo Credits FHI 360

In both provinces, the project supported MOHCC health facilities by handing over of 129 steel filing cabinets that will be used for storage of registers. In Midlands, the CHOs are also supporting MOHCC in the collection and transportation of CD4 and sputum specimens from local facilities to the district labs. This is a component that the project will intensify in Year 2 as part of community-health systems strengthening. 9. Administrative and Operational Issues During the period under review, 11 project vehicles were received and branded. Six vehicles were allocated to Manicaland province while four were allocated to Midlands province and one was retained at national office in Harare for coordination purposes. During the baseline assessment, a total of 10 vehicles were leased for Manicaland and Midlands provinces with an allocation of 6 and 4 respectively. This facilitated the smooth collection of data at health facility level, engagement of key informant interviews as well as focus group discussions.

22 motorbikes were procured and distributed to the 8 districts for use by the Community Health Officers. 20 of the CHOs were trained by the Riders for Health on how to use the motorbikes. It is anticipated that this improved mobility by the CHOs will further improve household testing, particularly accessing hard-to reach communities.

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Figure 12: ZHCT project vehicles, motorbikes and bicycles// Photo Credits FHI 360

Other procurements that were done during this period include 200 bicycles for Outreach Workers to aid their mobility at community level. The OWs were also equipped with mobile phone for use in defaulter tracking as well as supporting the retention in are and treatment. The OWs are a key cadre of the ZHCT project. For instance, the referral completion rate improved from around 30% in Q2 to close to 60% in Q3 following the recruitment of the Outreach Workers around mid-May.

All the 10 ZHCT project offices from national, provincial and districts levels have been branded in line with the Branding and Marking Plan. The branding has increased visibility of the project at all levels. All the offices have also been connected with internet, increasing the efficiency and effectiveness of project operations in the field towards achievement of targets.

Concerning capacity building, key ZHCT finance project staff attended an FHI 360 one-week training in Senegal in May that covered procurement management, sub-grantee management, travel management and USAID administrative and financial compliance requirements. All key FHI360 and Plan International project staff attended a one-week training on Sub-Award Management in Harare. These orientations will ensure compliance with USAID Rules and Regulations as FHI360 implements the Award. 10. Lessons Learnt The following are the key lessons learnt during the period under review:-  Uptake of HTS among male sexual partners of female index cases remains low. As the project moves to second year, innovative approaches will be utilized to target men who are normally at work during the time CHOs conduct household visits. Approaches under consideration include establishing HTS within selected workplaces, e.g. tea and sugar estates as well as timber plantations in Manicaland. Another consideration is conducting testing after working hours in order to reach more male partners of index cases.  Targeting of sexual partners of index cases is critical in achieving a higher yield. The current yield has been lower than expected from index testing. The main challenge has been poor targeting of HTS at household level as field data shows that CHOs are offering HIV testing to everyone (not just the sexual partner and children or parents of the index case). The HTS register has been revised to allow for better analysis of the yield across the different target groups. More entry points for identification of index cases have been added to improve on targeting for HIV testing.  Involvement community-based Outreach Workers is critical in improving linkage to care and treatment (particularly in defaulter tracking). However, documentation challenges in health facilities have resulted in misclassification of some patients whom upon follow up, up to a third of clients recorded at the facility as defaulters have been found to be still in care and up-to-date with their scheduled appointments.  Proactive engagement and coordination with other key HIV care and treatment partners in the provinces is crucial to minimize duplication of efforts and maximize on efficiency. Due to the

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prioritization of sites and districts, other partners offering HIV care and treatment are targeting the same districts as the ZHCT.  There is a difference in the acceptance of CARGs as an appropriate service delivery model by PLHIV and facility nurses between urban communities and rural communities. In some urban areas like Gweru and Rusape, the formation of CARGs has been slow as clients do not face challenges in reaching to facilities compared to areas like Buhera, Chipinge and Gokwe South. In Year 2, the project will be responsive to these dynamics in facilitating the formation of CARGs. 11. Planned Activities for Q4 (July 1 to September 30, 2016) In the Q4, ZHCT will intensify providing HTS services and lessons key lessons that will inform the scale- up to additional districts in the second year of the project. The following are key activities planned for Q4:-  Conduct the Annual Review and Planning Meeting July 5 to 7  Draft and submit Year 2 Annual Workplan to USAID by August 15  Refresher course of HIV Clinical Management for CHOs  Support renovation of Midlands and Manicaland laboratories  Recruit lab scientists and data entry clerk for each Mutare and Midlands provincial labs.  Baseline survey data analysis and production of baseline assessment report  Revision of indicators and data collection tools  DHIS2 database installation and customization  ZHCT project staff will participate in an FHI global technical meeting on Care and Treatment, PMTCT and OVC from September 5 to 7

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Annex I: ZHCT Annual Progress Summary

Baseline data FY 2016 Quarterly Status – FY 2016 Annual Comment(s) Data Performance Indicator Annual Annual Source 2016 Value Cumulative Cumulativ Q1 Q2 Q3 Q4 Achieved to Planned target e Actual Date (in %) Core Indicators

Number of individuals who receive HIV HTS 2016 N/A 11,582 11,543 0 1,285 10,258 99% The project is well on Testing and Counselling (HTC) services Register course to meeting the for HIV and received their test results annual target. Number of HIV-positive adults and 2016 N/A 31,788 This indicator will be children receiving care and support reported in Q4. services outside of the health facility Customized Indicators

Intensify community based HIV Testing Services Percentage of clients testing HIV HTS 2016 N/A 5% 6% 0 8% 6% 6% The overall positivity rate positive during the reporting period Register for Q3 was 6% with Midlands achieving 7% while Manicaland had a 5% yield. Integrated Symptom screening and referrals Percentage of new PLHIV who were HTS 2016 N/A 90% 100% 0 91% 100% 100% screened for TB symptoms at the Register community level during the reporting period Percentage of new PLHIV who are Referral 2016 N/A 70% 41% 0 17% 78% 41% successfully linked to care during Register reporting period Percentage of clients with a completed Referral 2016 N/A 70% 47% 0 43% 47% 47% referral to the health facility for health Register services Number of HIV-positive adults and Pre-ART 2016 N/A 811 330 0 44 286 41% children newly enrolled in clinical care Registers (Pre-ART) during the reporting period [CARE_NEW Adapted] Identify, target and build capacity of priority community based health workers for effective community level service delivery

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Baseline data FY 2016 Quarterly Status – FY 2016 Annual Comment(s) Data Performance Indicator Annual Annual Source 2016 Value Cumulative Cumulativ Q1 Q2 Q3 Q4 Achieved to Planned target e Actual Date (in %) Number of individuals trained in one or Capacity 2016 N/A 248 1533 0 140 1,393 648% all of the following; HIV testing, HIV Building care, HIV treatment, GBV during the Register reporting period Improve retention in care and treatment Proportion of ART defaulter clients Patient 2016 N/A 80% 47% 0 1% 47% 47% A total of 359 clients were tracked and successfully returned to Tracking successfully returned to care during the reporting period Register care after 948 clients were tracked within the community. Out of the 948 tracked 188 clients were confirmed to be in care and therefore, denominator used to calculate the proportion is 760. Strengthen access to viral load services through demand creation and referrals

Proportion of clients successfully linked Referral 2016 N/A B+5% 61% 0 0 61% 61% The greater proportion of to care for viral load testing from the Register clients (99%) who were community during the reporting period successfully linked are from Manicaland province in only two districts where the viral load services are currently available i.e. Mutare (126) and Buhera (89). Support the formation and function of community level ARV Refill clubs

Number of support groups formed or CARG 2016 N/A 100 15 0 15 242 257% identified and capacitated on community Summary HIV services provision within a Register and reporting period Capacity Building Register Support the formation and function of community level ARV Refill clubs Number of PLHIV receiving ARVs at CARG 2016 N/A 960 1,461 0 0 1,461 152% the community level through refill Monitoring groups during the report period. Register

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Annex II: Overall Implementation Status

Activities Key Benchmarks/Deliverables Status Project Start Up Activities  Conduct project planning and orientation meetings with key stakeholders at central and provincial  At least one planning meeting held with key stakeholders at each Done level. province and at national level  Recruit and position key personnel and other project staff.  100% of key project staff positioned at central level Done  Establish sub-agreements/subcontracts/MoUs with all key partners.  Sub-agreements/subcontracts in place with key partners at district Done and community levels  Finalize annual work plan, PMP and M & E plan for submission to USAID.  Annual work plan, PMP and Budget submitted and approved by Done USAID Conduct a landscape analysis in collaboration with stakeholders  Design and develop data capturing and mapping tools  Data capturing tools available Done  Conduct district service mapping in 8 targeted districts.  Districts service availability maps Done  Identify and map key hot-spots to be reached in each district with target populations  Hot spot maps generated for use by Project staff and CBHW Done  Mapping of youth friendly service providers targeting adolescents, girls and young women as well as  Report available for planning and implementation Done OVC  Conduct FGDs and IDIs in the target districts to understand quality of care and barriers to access  Barriers to access and retention identified for programing purposes Done and retention in the context of gender and other social norms  Collect baseline facility-based retention, viral suppression and related data in collaboration with  Key set of MER indicators constructed and recorded from facility Done OPHID data  Identify family planning services available at community level  List of community-based distributors of FP commodities Done Intensify community based HIV testing services  Development of Integrated Package for community based HTS  Integrated Package developed and in place Done  Orientation of CHOs and CPFs on index testing  No. of project staff oriented Done  Orientation of CBHWs on index testing  No. of CBHWs oriented Done  Community engagement and consultative meetings with MoHCC, PLHIV groups and other  Stakeholder buy-in, ownership and commitment Done stakeholders to promote household HIV testing  Develop/adapt SOPs (index case testing; data management; and tracking)  SOPs developed Done  Refresher training of community health officers in index patient testing  No. of CHO trained in index patient testing Done  Identification of index patients through PMTCT,TB, VMMC, PSI outreach, OI clinics, care groups and  Household members tested Ongoing refill groups and follow on visit to household members of the patient  Provide HTS in hotspots  Clients tested and linked to care and treatment services Ongoing  Introduce a risk and vulnerability screening tool for HIV negative individuals to all outreach workers  Screening tool used by all Outreach workers Ongoing  Strengthen risk reduction counselling and HIV re-testing for HIV-negative clients  HIV negative clients remain negative Ongoing  Conduct quarterly QA and supportive visits by the DNOs and the District Coordinators  Quarterly QA and support visit reports Ongoing  Conduct routine quality assurance of testing in line with ZINQAP  Quality testing provided to clients Ongoing  Establish functional community/facility referral systems in each district  Clear referral system established Ongoing  Review the ZIMPHIA study on Door to Door HIV Testing to assist ZHCT decide on the applicability  Recommendation for ZHCT Door to door testing model Not Yet of the model Preliminary report expected in December 2016 Provide symptom screening services and referrals at community level 23

 Adapt integrated care and support screening checklist for community cadres - to include TB, NCDs,  Checklists available for use Done FP, nutritional status and GBV  Orientation of community health officers and CBHWs in symptom screening using the integrated  CHOs, Outreach Workers and VHWs skilled in symptom screening Done checklist  Support the routine application of the integrated checklist by CHOs, Outreach Workers, VHWs and  Increased TB case detection, Identification of malnutrition, and Ongoing other community cadres NCDs. Identification of unmet FP needs and improved linkage to care  Strengthen referrals and linkages for symptomatic patients  Complete referrals for symptomatic patients Ongoing Identify, target and build capacity of priority community-based health workers for effective community level HIV services delivery  Identify key community based health workers that will be targeted as the mechanism for delivering  VHWs, Outreach Workers, Expert Patients identified for capacity Done community based services strengthening  Develop integrated training package for community based health workers  Integrated curriculum that addresses relevant technical areas Ongoing developed – treatment literacy, adherence counselling, IPC, FP, nutrition, index patient testing, Viral Load and M&E  Orientation of community-based health workers in relevant technical areas – treatment literacy,  No. of community-based health workers oriented Ongoing adherence counselling, IPC, FP, nutrition, index patient testing, Viral Load Improve retention in care and treatment  On-job refresher trainings of CBHWs on adherence counselling  No of CBHWs receiving on-job training Done  Orientation of outreach workers and VHWs on adherence using the integrated package  No. of Outreach Workers and VHWs oriented Done  Promote testing, early treatment, PHDP framework and address barriers to adherence particularly  Political, traditional and religious leaders engaged for promoting Ongoing with political, traditional, religious leaders adherence, testing and treatment and positive living  Utilize social media platforms to promote retention in care  Social media platforms for addressing retention utilized Ongoing  Generate defaulter and LTFU list on a weekly basis  Defaulter/LTFU lists available Ongoing  Reconcile community and health facility based registers to identify defaulters  Defaulter lists routinely generated Ongoing Strengthen support groups and care groups at the community level  Facilitate the formation and strengthening of support groups  No. of support groups formed and functional/ active Ongoing  Mobilize communities to support and facilitate adolescent testing for HIV  Communities engaged and are active in supporting adolescent Ogoing testing  Mobilize adolescents to take up testing services through the adoption of the ZVANDIRI model  Increase in number of adolescents presenting for testing Ongoing  Establish adolescent support groups  Adolescent support groups established and functional Not Yet Africaid recruitment in progress  Facilitate the hosting of community health events, e.g. men’s health days, family health days  No. of community health events supported Ongoing  Facilitate community engagement sessions with adolescents , pregnant mothers and young women  No of community engagement sessions conducted per target group Ongoing and men  Link groups with role models for cross learning and sharing of good community based care and  Skills transfer from mentor to mentees Ongoing treatment practices  Facilitate linkages and referrals with other IPs for care and treatment support services  No of clients linked/ referred for appropriate services Ongoing Support formation of community ARV Refill Groups  Support the MOHCC to conduct stakeholder consultation for the development of the Community  Stakeholder consultation report developed and disseminated Ongoing Delivery of ART framework  Provide Technical Assistance to MoHCC for the development of the strategic framework for the  A National Framework is developed and finalized Ongoing delivery of community based HIV care and treatment services

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 Develop guidelines and SOPs for supporting ART refill clubs  SOPs developed/ adapted and in place Done  Facilitate the establishment of the ART refill groups for adherence and retention in care and treatment  ART refill groups established in the 2 provinces Ongoing for PLHIV  Conduct orientation for the ART refill groups  ART refill groups oriented Ongoing  Support ART refill clubs meetings through the Outreach Worker  All ART refill clubs are functional Ongoing Strengthen access for viral load services  Conduct referrals for viral load testing  PLHIV referred for VL test Ongoing  Develop/adapt educational materials for viral load treatment literacy  Viral load treatment literacy/ messaging materials developed/ Not Yet adapted  Collaborate with OPHID to support site level activities - clinician VL job aids, sample collection and  Uptake of available VL services is optimal Ongoing transport, results retrieval and documentation, data review meetings.  Enhanced treatment literacy training for adherence Outreach Workers and Support Group leaders  Improved capacity of Outreach Workers and Support Group Not Yet leaders to support clients on ART Address the dynamics of stigma, gender and social norms as a means to improve retention  CPFs and Outreach Workers conduct community dialogue sessions to provide support for PLHIV to  No of community dialogue sessions conducted Ongoing practice self-care including remaining in long term treatment  Orient the CPFs and the Outreach Workers in the use of in FHI 360’s C-Change’s Model to improve  No of CPFs and Outreach Workers oriented on the C-Change Ongoing adherence retention and viral load suppression Model  Disclosure support for the PLHIV through family conferencing Ongoing  PLHIV supported in practicing self-care which will be adapted to meet different literacy levels Ongoing Provide differentiated care and support for adolescent girls and young women  Identify and utilize community support networks for young people  Networks including social media platforms identified and Not Yet operationalised  Identify and adapt appropriate approaches/ models currently in use to mobilise young women,  Models/ approaches identified and adapted Ongoing adolescents and men, e.g. ZVANDIRI, Join In Circuit, Male Mobilisers, SAYWHAT  Mentor young women as role models to provide other young women with positive support in  Mentors matched with mentees Not Yet treatment care and retention.  Engage schools and communities through Sport as an entry point for delivering messages on self-care  Sporting events for delivery of self-care messages Not Yet  Facilitate and support peer-led community dialogues for adolescents, men and young women to  No. of community dialogues held with target populations Ongoing promote age specific issues related to treatment, positive norms and behaviours among their peers  Identify expert patients to provide youth friendly and age and gender specific treatment, care and  No. of expert patients identified and providing support services Done retention support services Strengthen M&E system for HIV care and treatment at community level  Develop/ adapt community M&E tools for the project (including, referral register, tracking tools,  M&E tools developed/ adapted Done community based appointment register, defaulter tracking register)  Develop/adapt standard operating procedures for the community-based health workers to use for  Patient tracking SOPs developed/adapted Done patient tracking  Orient MEAs, CHOs, CPFs, and CBHWs on data management and data capturing tools  Project staff oriented Done  Submit monthly summary report to MoHCC through their reporting system  Monthly reports submitted to MoHCC Ongoing  Conduct monthly data validation exercises  Verified data available Ongoing  Conduct quarterly DQA exercises  DQA reports shared Ongoing  Conduct monthly data review meetings at district level  Monthly data review meetings held Ongoing  Develop and maintain ZHCT project database  ZHCT project data base developed and utilized Ongoing

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Annex III: Success Story: Benefits of CARGS HIV patients enjoy the benefits of a Community ART Refill Group (CARG)

helton Mangwende2 is a 49 year old HIV positive and stable patient who is enjoying the benefits of a Community ART refill group (CARG) in Bhamala village of Kwekwe District. Shelton was diagnosed S HIV positive in 2012 following the diagnosis of his first wife aged 41 in 2008. Shelton has 3 wives and the other two aged between 30-51 years were diagnosed HIV positive between 2010 and 2012.

Out of the 6 children, 2 were also diagnosed HIV positive and were initiated on ART at Donjuan, a local health facility, which is 10 kilometres away from their homestead. “The major challenge that I faced before the formation of this CARG was to raise money for transport; for my family to go and collect our medicines from the health facility. Most of the times, we ended up selling our chickens to raise money for transport”. This is one of the stark realities experienced by people living with HIV on ART as some health facilities are not within easy reach.

It is under these circumstances that Zimbabwe HIV Care and Treatment (ZHCT) project staff facilitated the formation of Kufainguva Community ART Refill Group (CARG) to ease transport challenges for clients on ART such as the Mangwende family; as well as decongesting Donjuan health facility. Mr Mangwende, his 2 wives and daughter, formed the CARG in May 2016 together with 8 other community members in their neighbourhood, to ease the burden of traveling to the facility every other month for resupply. Mr. Mangwende’s second wife who is the CARG leader says that, “It is irresponsible in this day and age to die of HIV/AIDS because of failure to disclose to one’s family”. Such positive attitudes encapsulates the aim of the CARG model, which is to improve the retention of patients on ARVs, reducing the number of visits to the health facility to collect their medicines. Avoiding treatment interruptions or discontinuations is one of the main challenges that clients on ZHCT project grapple with on a daily basis. The third wife who is Members of Kufainguva CARG// photo credits FHI360 pregnant is not a CARG member allowing enough resources for her to visit the nearest health facility every month for her antenatal care and PMTCT. His 12-year-old daughter who is on ART, is not part of the CARG as she does not meet the eligibility criteria.

The 12 CARG members visit the clinic on a rotational basis to collect the drugs for the rest of the group.

Currently, only one member of the family along with the third wife can visit the facility and they do not have to walk long distances anymore. The CARG can now afford transport costs of $2 return trip to the health facility. None of the family members on ART has defaulted as they remind each other to take their medication daily. Being part of the CARG with their neighbours enables the Mangwende family to share ideas, experiences, challenges and information. The other four children together with their niece and nephew were tested by FHI360 project staff at their homestead and they are HIV negative.

2 Not his real name

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