Meeting Targets and Maintaining Epidemic Control (EpiC) Project
Cooperative Agreement No. 7200AA19CA00002
CÔTE D’IVOIRE QUARTERLY PROGRESS REPORT JULY 1 TO SEPTEMBER 30, 2020
SUBMITTED BY FHI 360: OCTOBER 30, 2020
EpiC Côte d’Ivoire Quarterly Progress Report July 1 to September 30, 2020
A. SUMMARY OF KEY RESULTS This report covers activities and performance of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project in Côte d'Ivoire (EpiC CI) for quarter four (Q4) of FY20. The EpiC CI project is being implemented in eight health regions composed of 20 sites, each representing a health district or a commune. In Q4, the project continued to support local implementing partners in providing HIV prevention interventions to key populations (KP) and their sexual partners, as well as care and support to people living with HIV (PLHIV). HIV case finding, linkage to ART, and support for ART retention remained a priority of the project team despite the context of COVID-19. To ensure annual targets were met, the project team provided both virtual and physical technical suppors to implement index testing, and standard outreach activities at targeted hot spots in compliance with the PEPFAR COVID-19 guidelines. In Q3, the project had achieved over 70% of its contractual targets for all indicators except for index testing. To catch-up and meet the minimum requirements for index testing, the project conducted a refresher training for outreach workers who are authorized to perform HIV testing in the community. After the training, index testing implementation was accelerated to boost case identification and meet the annual HTS_TST_POS targets. During Q4, the project team was heavily involved in the preparation for COP 20 where eleven (11) new clinical sites will be transitioned to EpiC CI project from CDC supported sites. This involved site assessments to identify sites’ needs and gaps that may affect the performance and quality of services provided by those sites. USAID, CDC, and the Ministry of Health (MoH) played crucial roles in this activity. Details of the gaps and needs of the sites are provided in this report in a specific section about COP 20 readiness. Key Populations Investment Funds (KPIF) funding supported local implementing partners (IP) to ensure all HIV positive KPs and non-KPs were linked to ART, scale-up pre-exposure prophylaxis (PrEP) initiatives, support newly established Drop-In Centers’ (DIC) activities and services as well as supporting the transition to COP 20. Below is a summary of key results for Q4 FY20: • 2,672 female sex workers (FSWs), 2,313 men who have sex with men (MSM), and 3 transgender (TG) individuals (a total of 4,988) were reached with HIV prevention interventions; • A total of 2,274 people (913 FSWs, 1,015 MSM, 2 TG people and 344 members of Priority Populations (PP)) were tested for HIV and received their results; • 130 FSWs, 189 MSM, 1 TG person (a total of 320 KPs) and 74 members of PPs were tested positive for HIV and 99% of them were linked to health facilities for their ART initiation (125 FSWs, 189 MSM, 1 trans individual, and 74 members of PPs); • 236 (146 FSWs and 90 MSM) diagnosed with HIV were offered index testing services; from them, • 609 contacts were elicited and tested, 135 tested positive for HIV and all were initiated on ART within the quarter; • 2,318 HIV self-testing (HIVST) kits were distributed; • 189,764 male condoms, 14,912 female condoms, and 38,661 water-based lubricants were distributed to KP members and their sexual partners; • 104 individuals (26 MSM, 76 FSWs, 1 TG and 1 stable partners of FSWs) were referred to STI services, 22 individuals were screened and diagnosed (12 MSM, 8 FSW, 1 stable partner of FSW and 1 female sexual partner of a MSM) and 19 were treated (9 MSM, 8 FSW, 1 stable partner of FSW and 1 female sexual partner of a MSM); • 13 individuals (1 FSW and 12 MSM) were referred for GBV.
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Table 1. Percentage of FY20 annual targets achieved through Q4 (KP and All Pop) Achieved Annual % achievement Indicators
Target # Q1 # Q2 # Q3 # Q4 Total – LOP thru Q4 Population KP_PREV 15,105 4,006 7,150 5,674 4,988 21,818 144% HTS_TST 11,673 2,445 4,705 3,233 1,930 12,313 105% HTS_TST_POS 1,514 199 552 433 320 1,504 99%
101% of annual p target achievement and
Key po Key TX_NEW_VERIFY 1,438 172 520 440 315 1,447 96% linkage of new positive cases
HTS_SELF 4,026 268 673 1649 2,318 4,908 122% KP_PREV 15,105 4,006 7,150 5,674 4,988 21,818 144% HTS_TST 12,420 2,614 2,847 3,621 2,280 11,362 91% HTS_TST_POS 1,682 247 582 519 394 1,742 104%
All pop All TX_NEW_VERIFY 1,598 216 517 429 389 1,551 97% HTS_SELF 4,026 268 673 1,649 2,318 4,908 122%
Table 1 provides a summary of the EpiC CI achievements compared to the annual targets for the main project indicators:
1. KP_PREV: a total of 21,818 KPs were reached by the prevention interventions, representing an achievement of 144% to the 15,105 KPs targets for FY20. In Q3, the project had already surpassed the annual targets (111%) for KP_PREV but the project continued to offer prevention interventions to KP members to increase HTS_TST and HTS_TST_POS performance which were respectively 89% and 78% at Q3.
2. HTS_TST: a total of 12,313 KPs were tested from all testing modalities, representing 105% of the FY20 HTS_TST target;
3. HTS_TST_POS: a total of 1,504 KP members were diagnosed with HIV, representing an achievement of 99% compared to the FY20 targets.
4. TX_NEW_VERIFY & TX_NEW: 96% of the KPs identified HIV positive were successfully linked to ART during FY20.
5. HTS_SELF: a total of 4,908 individuals received HIV self-testing kits, representing a rate of 122% of HTS_SELF annual target.
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B. KEY RESULTS BY OBJECTIVE
1. Result 1. Attain and maintain HIV epidemic control among at-risk adult men, women, and priority populations (PPs) and Result 2. Attain and maintain HIV epidemic control among key populations (KPs)
Reached KP members with HIV prevention interventions: Figure 1: Summary of the main direct service During Q4 FY20, the EpiC CI team provided regular technical delivery results among key populations, July to support to all 13 local CBOs/implementing partners to reach September 2020 and provide HIV prevention interventions to KP members in the community. In total, 4,988 individuals (2,672 FSWs, 2,313 MSM, and 3 trans individuals) were reached with HIV prevention interventions in Q4.
KP members offered HIV testing services: In Q4, a total of 1,930 KP members (913 FSWS, 1,015 MSM, and 2 trans individuals) and 350 non-KPs (a total of 2,280) were tested for HIV through various modalities including 1,563 from standard outreach, 609 from index testing, 77 from the EpiC supported DICs,30 from clinical and 1 from Go Online in Q4. For HIVST, 43 tests were reactive and 42 were confirmed HIV positives. HIVST were used as an alternative testing option for KPs and PPs who declined testing from standard outreach and for those who are hard to reach such as partners of HIV positive KP members.
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1.1. Testing cascade analysis by testing modality (for all populations), July – September 2020
Figure 2: Variation in HIV case-finding rates by modality for all population. July – September 2020
1800 Tested Tested HIV positive Case-finding rate 120% Go Online Clinique DIC Index Testing Outreach 1563 1600 100% 100% 1400 2%
1200 80% 0% 3%
1000 The case-finding rate by type of population are 60% 800 14% for FSWs, 19% for MSM, 50% for trans, and 21% for other 609 600 populations 40% 34% 22% Number of KP members KP Numberof 20% 400 17% 15% 20% 61% 200 77 1 1 30 6 13 135 239 0 0% Go Online Clinique DIC Index Testing Outreach
Testing Modalities
According to figure 2, the highest volume of tests and positive HIV cases were found through standard outreach. This contributed 61% of all HIV-positive cases identified during this reporting period. Index testing contributed 34% of HIV-positive cases, 3% for DIC, and 2% for partners offering clinical services.
A total of 2,280 individuals, KPs and non-KPs (350 PP and 1,930 KPs), were tested for HIV in Q4, making a cumulative result of 13,362 individuals tested (1,149 PP and 12,213 KPs), and representing an achievement of 108% of the HTS_TST annual target (12,420). Of all KP and non-KP tested in this reporting period, 394 HIV positive cases were identified. Cumulatively for FY20, 1,742 HIV positive cases were identified , representing an achievement of 104% of the annual HTS_TST_POS FY20 targets (1,682) and a case finding rate of 13%. Of a total of 394 individuals tested HIV positive in Q4 (KP and non-KP), 389 individuals were successfully linked to ART. In total 1,678 HIV positive individuals were linked to ART in FY20, representing 96% linkage rate. KP specific data shows an overall case finding rate of 17 %.Among the 320 KP members newly diagnosed with HIV in Q4 315 (98%) were successfully linked to ART services and initiated on ART within the quarter. Cumulatively, 1,504 KP individuals were diagnosed as HIV positive, of which 1,447 were linked to ART services, representing 101% achievement of the annual target (1,438) for TX_NEW_VERIFY .
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Figure 3: Trend in case finding among all populations
HTS_TST HTS_TST_POS Case finding
6,000 17% 18%
4,847 16% 5,000 14% 14% 12% 4,000 3,621 12% 9% 10% 3,000 2,614 2,280 8% 2,000 6% 4% 1,000 582 519 247 394 2% 0 0% FY20Q1 FY20Q2 FY20Q3 FY20Q4
Figure 3 gives a summary of the testing and case finding results during FY20 for all populations and shows the trend in testing volume and case finding. The highest volume is observed in Q2 with over 4,847 individuals tested and with the highest number of HIV positive cases identified. Low performance in Q1 was due to a delay in project commencement, so the project team and local CBOs accelerated the implementation which lead to high performance in testing and case finding in Q2. In Q3, the project continued to provide testing services but due to the COVID-19 outbreak, testing volume went down. At the end of Q3, program data showed good progress toward the annual targets for testing and HIV case identification but a low performance in terms of volume, which was due to the COVID-19 outbreak and country lock down that affected outreach and testing at KP hotspots. In Q4, small businesses could open and outreach activities resumed in all project supported sites. After analysis of the three first quarters, index testing was not being offered to all those newly diagnosed on a systematic basis but case finding results were high. In Q4, Ihe program focused on ensuring ART initiation for those newly diagnosed as well as systematically offering index testing Index testing was also systematically offeredto those who were previously diagnosed but had not been previously offered the service.
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Figure 4: Index testing cascade in CI for all populations, Q4 FY20
Index offered Index accepted Contacts 700 Not tested - Positive at entry Tested - Positive Initiated ART 61 Kps and 74 600 non Kps 2.6 Contacts 135 500 elicitation rate
400
300 609 74% 97% 100% linked to 474 ART 200 320 22% case-finding 236 rate 100 230
135
0 HTS_TST_POS Index offered Index accepted Index contacts Contacts tested Initiated ART treatment
Figure 4 shows that 97% of the 236 HIV-positive cases accepted index-testing services and provided contact information of their sexual partners,and/or children. Acceptance rate was high compared to previous quarters due to the sensitization and refresher training on Index testing to health care staff. Contact elicitation rates was on average 2.6 and the case finding was higher (22%) compared to other modalities. The 135 diagnosed HIV-positive were all (100%) successfully linked to ART and initiated on treatment within the quarter.
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Figure 5. KP index-testing cascade for FSWs and MSM, Q4 FY20
FSWs MSM MSM
350 Stable partners of FSWs Regular clients of FSWs Female sexual partners of MSM Biological children of FSWs 31 300 2.3 23 250 contacts ratio for FSW 200
327 150 97% Accepted Index Testing 273 19% case 100% finding linked to
Number people of Number rate 100 ART rate 130 146 142 6 6 50 3 3 52 52 0 HTS_TST_POS Offered Accepted Contacts elicited Contacts tested for Contacts newly Contacts linked to HIV identified positive ART FSWs Index Patients
300 23 250 3.2 contacts 200 ratio for MSM
150 282 98% Accepted 259 26% case 100% linked Index Testing finding rate to ART rate 100
Number people Number of 190 13 13 50 90 88 61 61 0 HTS_TST_POS Offered Accepted Contacts elicited Contacts tested Contacts newly Contacts linked for HIV identified to ART positive MSM index clients
Data in Figure 5 shows a high volume of contact elicitation from FSWs but lower compared to the MSM ratio. Case finding and acceptance rates were higher among MSM compared to FSW (19% vs 26% and 97% vs 98%), but still a successful approach to offering testing to those at high risk of HIV infection. In this quarter, 31 biological children of FSWs were offered HIV tests and 6 were found to be HIV positive (19% case finding) – all of them were linked and initiated ART. From the 609 contacts elicited, 259 were MSM, 273 were stable partners of FSWs, 23 were regular clients of FSWs, 23 were female sexual partners of MSM, and 31 were biological children of FSWs. In FY21, the EpiC CI team will continue to support local implementing partners in monitoring index testing services and data to ensure services meet the PEPFAR
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recommended standards. An improvement plan will be developed for those who do will not meet the required score on the RedCap assessment. Community-led monitoring (CLM) will be conducted at the sites to identify any adverse events and other issues related to the index testing services. In addition, CBOs were trained on safety and security of KPs and reporting of adverse events to respect the principle of “do no harm” within HIV services.
Figure 6: HIVST cascade, Q4 FY20
Assisted Unassisted 2500 43.2 87 43 0 0 1. 96% of HIVST kits were done 2000 through assisted distribution Figure #6 shows a total of 2,318 HIVST kits distributed and42.8 used by KP and non-KP via index testing. , of which 99% were done through assisted distribution. 43 of42.6 the 2,318 screened turned reactive. Among the 43 reactive, 42 were confirmed HIV positive (98%). Case finding rate from HIVST was at 2%. 1500 42.4 Cumulatively 4,903 HIVST kits distributed in FY20, representing 122% of the annual target achievement. In the contex2351t of COVID-19, HIVST2318 has helped increase access42.2 to HIV testing43 and test43 kits were used as an1000 option for those who declined tests and for 2231sexual partners of KPs who are hard to reach. 42 0 0 1.2. KP Cascade Analysis 41.8 500 case 42 42 findin 100% 93% NumberHIV of Self tests 41.6 100% 99% 100% g rate2 % 41.4 0 Screened Linked to HIV Confirmed Link to ART Kits Received Kits distributed Persons Screened Reactive testing services Positive
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Figure 7. Cumulative cascade for all KPs through Q4 FY20 Not Eligible
Status not recorded 21,818 (144%) Known positive
20,000 3408 Declined 4,988 23 Referred for 0 testing/Tested
4029 1514 15,000 15,105 1504 (99%) 1438 5,674 1400 1447 (101%) 320 315 12,313 (105%) 1200 11,673 1,930
Number of KP of Number 10,000 1000 433 440 3,233 800 7,150 14358
Number of KP of Number 600 5,000 4,705 552 520 400 96% linked to 12 % Case 4,006 ART Finding200 2,445 199 172 - KP_PREV KP_PREV Disag HTS_TST 0 HTS_TST_POS TX_NEW_VERIFY
Figure 7 illustrates the prevention cascade of all KPs, from those reached to those successfully linked to ART in Q4. Cumulatively, the project surpassed the annual targets for KP_PREV, HTS_TST and TX_NEW_VERIFY. In total, 12,313 KP received HIV testing and 1,504 were diagnosed with HIV in FY20. The overall case finding rate is at 12% and linkage to ART services at 96%.
In Q4 specifically, 3,876 benefited from testing services, after excluding those with low risk (472), those who declined testing (634), and those with known HIV status (6). Overall, the case-finding rate improved from less than 10% in Q1, to 12% in Q2, to 13% in Q3 to 17% in Q4. Case finding from index testing in Q4 increased to 22% and boosted the overall case findings from all testing modalities. With KPIF, peer navigators received transport and communication fees to improve the linkage-to-ART rate from 87% in Q1, to 94% in Q2, and 96% in Q3 and Q4.
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Figure 8. Cumulative cascade for FSW populations through Q4 FY20 Not Eligible 1000 14,000 Status not recorded
13,132 (142%) Known positive 900 Declined 861 12,000 2,672 2,415 818 Referred for 800 782 (91%) 20 testing/Tested 742 (91%) - 130 700 10,000 125 2,547 9,222 3,366 600
8,000 210 7,113 (103%) 500 218 6,888
913 KP of Number Number of KP of Number 6,000 400 1,668 4,396 300 293 4,000 8,150 11 % Case 275 Finding 2,738 200
95% 2,000 linked to 100 ART 2,698 149 124 1,794 0 - HTS_TST_POS TX_NEW_VERIFY KP_PREV KP_PREV Disag HTS_TST
The FSW cascade in the above figure 8 provides details of prevention and testing services FSWs received from October 1, 2019 through September 30, 2020. Year to date results show 782 HIV positive cases among FSWs, all testing modalities combined, with an overall case-finding rate of 11% and a linkage-to- ART rate of 96 %. Q4-specific data shows a case-finding rate of 14% for FSWs with a 96% linkage-to-ART rate. The number of FSWs who were diagnosed with HIV this quarter (130) represents 41% of the total HTS_TST_POS results (320 KP members)
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Figure 9: Cumulative cascade for MSM populations through Q4 FY20 900 Not Eligible Status not recorded Known positive Declined 10,000 Referred for testing FY20 Q4 Results FY20 Q3 Results FY20 Q2 Results 800 FY20 Q1 Results Total Results 9,000
8,537 (154%) 705 (127%) 700 691 (131%) 8,000 974 3
2,313 190 600 190 7,000 1,465 556 528 6,000 500 5,529
5,000 2,276 5,092 (138%)
Number of KP of Number 400 220
1,015 219 Number of KP of Number
4,000 3,708 300 1,538 3,000 6,095 2,647 14200 % 2,000 Case 245 98% 234 Finding linked to 1,888 ART 100 1,000 1,301 651 50 48 - 0 KP_PREV KP_PREV Disag HTS_TST HTS_TST_POS TX_NEW_VERIFY
Figure 9 reveals greater case-finding and linkage-to-ART rates among MSM compared to FSW. Year to date results show a total of 190 HIV-positive cases found among MSM through all testing modalities, with a case-finding rate of 14% and a linkage-to-ART rate of 98%. Q4-specific data show a total of 1,538 MSM tested, an improved case-finding rate of 19 percent, and a linkage rate of 100%.
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Figure 10. Cumulative cascade for TG populations through Q4 FY20 Not Eligible 1,200 100 Status not recorded 97 92 1,077 90 1,000 80
70 800 60
600 50
40
KP of Number 400 354 30 17 (18%) 20 14 (16%) 200 149 (42%) 0 108 (99%) 3 0 32 1719 10 3 17% Case 83% linked 27 14 (14%) 11 (11%) 107 113 79 Finding to ART - 7 - 0 KP_PREV KP_PREV Disag HTS_TST HTS_TST_POS TX_NEW_VERIFY
Figure 10 shows a cumulative cascade of TG individuals. In total, 108 TG people were tested during FY20, 17 were identified as HIV positive (18% of case finding rate) and 15 were successfully linked to ART (83% of case finding rate). In Q4, 2 TG people were tested, of whom just one (50%) was found HIV positive and was linked to ART services. In the above TG cascade, testing targets were higher than the KP_PREV targets and were allocated in Adjame, one of the sites in Abidjan. There has been a challenge to reach an increased number of TG individuals and the total population size remains unknown in the country. In FY21, EpiC CI will work with CBOs such as Alternative and Arc-En Ciel to improve TG programming.
1.3. Variation in HIV Case Finding by Age Group, Sites, Variation in Linkage-to-ART Services
Figure 11. Variation in HIV case detection by age group among all KPs, Q4 FY20 Tested Pos Case finding rate
700 659 67% 70% 584 59% 600 60% 500 50% 400 37% 40% 31% 292 300 30% 177 17% 17%
Number of KPsof Number 200 20% 13% 121 98 83 65 100 4% 50 38 10% 7 24 17 10 15 10 0 0% <20 20-24 25-29 30-34 35-39 40-44 45-49 50+
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Figure 11 shows the variation in HIV case finding rates when compared by age group. Throughout FY20, program data has shown a high case finding among older KP; however the number of KPs aged between 35 and above is very small compared to the younger age groups. The program is continually engaging the MSM community to find effective strategies to improve the REACH and TESTING among older MSM. The same trend (e.g. older age groups have higher case finding) is observed across all KP types and from all testing modalities. EpiC CI had recruited older KP individuals and trained them as peer educators to target older KPs but this strategy has not produced high results. PEs have been reporting that older KP are hard to reach, do not share their contacts, and do not want to expose themselves or share their sexual orientation. Analysis from EPOA have been conducted to explore the dynamic between older peer mobilizers and who they are able to recruit for testing among their networks to better understand how age may influence recruitment patterns. Risk assessment results that explores age differences between partners can also be explored to develop outreach.
Figure 12. Variation in HIV case finding among all KPs across districts, Q4 FY20
Tested Case Finding Rate 600 53% 60%
500 50%
400 35% 40%
KPs 27%
of 300 23% 30% 18% 19% 200 15% 15% 16% 20% 11% 12% 12% 13% Number 10% 11%
100 10% Case detection rates 0%6 253 145 35 60 42 526 82 59 69 204 36 82 251 65 15
0 0%
Divo
Oume
Tabou
Katiola
Soubre
Gagnoa
Anyama
Korhogo
Mankono
Sassandra
San_Pedro
ube
Vridi
Cocody_Bingerville
Treichville_Marcory Bouake_Nord_Ouest
Health district Koumassi_Port_Bouet_ Adjame_Plateau_Atteco
Figure 12 shows an uneven distribution of case finding across the 16 health districts for all KPs. Overall, case-finding rates improved in Q4 among all supported sites. The highest case-finding rates (varying from 18 percent to 53 percent) were found in Koumassi-Prot Bouet-Vridi, Mankono, Cocody-Bingerville, Treichville-Marcory and Anyama, although these sites had the lowest testing volume. Abidjan sites, including the district of Adjame-Plateau-Attecoube, had the highest testing volume and 13 percent case- finding rate. Site performance also reflects partners’ performance operating from each of the supported sites (details of site and CBO’s performance are provided in the appendix).
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Figure 13. Variation in linkage to ART by age among all KPs, Q4 FY20
TX_NEW TX_NEW_VERIFY HTS_TST_POS % Linked to ART
120 120% 100% 100% 100% 100% 100% 100% 100 92% 100% 98 80% 80 83 80%
67 60 60% 53 50
Number people Number of 40 38 40% 44 24 20 28 20% 30 31 21 7 10 10 5 7 9 8 0 2 6 3 1 0 0% <20 20-24 25-29 30-34 35-39 40-44 45-49 50+
Figure 13 shows the highest volume of individuals diagnosed HIV positive are mainly 20–29 years old and a good linkage-to-ART rate across all age groups except 50+ years olds which had a 80% linkage rate.
Figure 14: Negative cascade - FY20Q4
250 PreP_NEW PreP_NEW_VERIFY PreP_CURR PreP_CURR_VERIFY
1650 200 1600 1550 150 1500 176 1450 100 1400 1610 96 1350 1300 50 1356 81 1250 84% 6% 44 44 1200 0 KPs tested negative KP having received a PrEP KP referred to PrEP PreP_NEW & PreP_CURR & proposal PreP_NEW_VERIFY PreP_CURR_VERIFY
A total of 140 individuals were initiated on PrEP in Q4, of whom 41 initiated at the EpiC supported DICs (AEC and Espace Confiance). The remaining PrEP users were referred and initiated in public health facilities supported by CDC implementing partners. Of the 140 who initiated PrEP, 99 (70%) chose daily PrEP. Some of those initiated in Q4 werethe result of Q2 and Q3 referrals.
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Those who accepted PrEP referrals were few compared to the larger number of KP who test HIV negative and are at risk. PEs report that the limited number of sites providing PrEP within a district and the sensitization around limiting visit to health facilities in the context of COVID-19 caused the low numbers. EpiC CI will continue to support the MoH/PNLS in producing IEC materials, training additional PrEP prescribers, and expanding PrEP sites in FY21.
In most of the EpiC supported sites, PEs and PNs provide messages around the advantage of taking PrEP to raise awareness and increase demand for PrEP. Some KP in EpiC sites were willing to take PrEP but services were not available at those sites including Mankono, Katiola, Ganoa, Soubre among others. EpiC has advocated with PNLS to expand the number of PrEP sites but the MoH proposed to first assess and learn from the approved 28 PrEP pilot sites and scale-up based on the results.
2. Improve program management (including health information systems [HIS] and human resources for health [HRH]) and financial systems to ensure attainment and maintenance of epidemic control
Data validation: Despite the COVID-19 context, the project team continued to support CBOs in ensuring data quality from all supported sites. Monthly data validation was conducted, and monthly data was submitted every 5th of the month. During this reporting period the team conducted verification and validation of the TX_NEW_VERIFY at all the referral sites for the period of July to September 2020. The common issues found during the data validation included data entry errors into the DHIS 2 tracker, poor filing of data collection tools in some sites, and issues with CBO’s understanding of indicator definitions and disaggregation. After the validation, all the CBOs received feedback on identified weaknesses and remediations plans were developed to improve data quality with focus on addressing data discrepancies.
RDQA in Soubre (ORASUR): It came to the attention of EpiC CI and HQ management that one of the CBOs (ORASUR) supported by the project was accused of reporting false HIV positive cases on a CDC/PEPFAR- funded project. FHI 360 leadership recommended a Data Quality Audit (DQA) to ensure EpiC CI data are not affected by the fraud. A DQA was conducted in Q4 with collaboration with the Soubre district. Results showed no signed of fraud. After the presentation of the results, USAID recommended to continue data verification, particularly, HTS_TST; HTS_TST_POS and TX_NEW_VERIFY and where possible add an option of calling the patient to ensure they exist. EpiC CI will join the PNLS in their DQA so that all the sites that will be supported in FY21 are audited and data are reliable. The overall analysis of the data audited during this RDQA show that ORASUR data are acceptable for the HTS_TST and excellent for HTS_TST_POS and TX_NEW_VERIFY.
Performance monitoring and feedback: During this reporting period, the EpiC CI team continued to monitor CBOs’ performance and track key indicators on a weekly basis. Real time data are entered into the EpiC CI DHIS 2 tracker by the CBOs’ staff. After verification and correction of the entered data, feedback was provided to each of the CBOs with a dashboard displaying the progress on the key indicators. A dashboard showing the performance of each partners is then shared through email and Whatsapp groups to create a positive influence and a competition to be at the top of other partners. With that spirit, CBOs data quality has improved and reports are provided on time. Partners with performance issues, were reached by the program team to ensure they received tailored support and improved their performance. In Q4, only ORASUR was in red with difficulties meeting the expected case finding rate despite all assistances received from the EpiC CI team. The EpiC CI team will continue to support local CBOs to improve their performance through regular performance review, in-service trainings, coaching, and supportive supervisions.
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C. Key Population Investment Fund (KPIF) KPIF funds are integrated into EpiC CI activities and continued to support the scale-up of PrEP, establishment of three DICs, and care and support activities with peer navigators. Contribution and achievements supported by KPIF are summarized below:
• With KPIF funding, EpiC – CI has improved case finding rates by training additional Peer Navigator/ Peer Educator on Index testing and distribution of HIV self-testing. • At the end of the fiscal year (FY20): 1,504 KPs were identified as HIV positive and 1,447 (96%) were successfully linked to ART services by Peer Navigators (PN). KPIF helped the program to recruit additional PNs and train them on PLHIV care and support as well as adherence counselling. PNs and Peer Educators (PE) were also trained on Index testing and GBV prevention and response. 120 PEs and PNs received refresher training on Index testing and peer navigation. 30 (15 PE and 15 PN) were trained on GBV prevention and responses. • During Q4, KPIF supported care and treatment interventions by providing differentiated support to PLHIV in the communities. Support included items such as providing reminders for clinical appointment and discussion for ART refill in the context of COVID-19. Care and support was based on the client needs, PNs sensitized PLHIV in their cohort about the risk for COVID-19, dispensed ARV in the community in collaboration with referral sites, did follow-up call to unstable patients and sent SMS reminding patients for their Viral Load sample collection date. KPIF have providing transport fees to PNs and patients. In this reporting period, EpiC CI has contributed to the second and third 95 goal by supporting 22 to access Viral Load tests of which eight had suppressed VL as shown in the below graph.
Figure 15: Positive Cascade FY20 Year to Date, All Populations
TX_NEW TX_NEW_VERIFY 1,200 TX_CURR_VERIFY TX_CURR 1,600 25
1,400 1,000 20 1,200 800 1,000 15
600 800 1,306 926 1,504 22 10 600 400
400 5 200 8 200 310 101 141 0 0 0 Currently on TX: VL_ELIG HTS_TST_POS TX_NEW & VL Tested: TX_PVLS VL Suppression: TX_CURR & (D) & TX_PVLS (N) & TX_NEW_VERIFY TX_CURR_VERIFY TX_PVLS_VERIFY (D) TX_PVLS_VERIFY (N)
Despite that EpiC CI was providing community HIV related interventions focusing on the first 95 of the UNAIDS goal, the project has contributed a lot in the second and third 95 goals through PN and other Human Resource for Health (HRH) support. On average, one PN provides provide care and support to 20 to 25 PLHIV (1,504/73). The main challenges EpiC CI has faced is how to quantify the efforts. Some referral sites do not provide feedback to PNs on the status of the patients linked in their facilities to help with
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retention and tracking on any lost to follow. Data in figure 15 do not represent the EpiC CI contribution but a representation of data capture from few referral sites based on the quality of the collaboration with them. In FY21, EpiC CI will continue improve collaboration with clinical partners and support new EpiC CI clinical sites to have ARV national codes so that the positive cascade can be improved. • KPIF has also help expand PrEP services to KPs members at the three Drop-in Centers (DICs) and other authorized PrEP facilities in the country. In total, there are twenty-eight facilities that are authorized by the government to provide PrEP, and those include three newly established DICs. In Q4: o 220 KPs (107 MSM and 113 FSW) were initiated on PrEP by the end of September 2020; o Of those 220, 157 are on daily PrEP and 63 on Event Driven PrEP (ED PrEP); o 44 of those who initiated PrEP are enrolled at the EpiC supported DICs.
• Through KPIF funding, EpiC played a significant role in the distribution of the HIV self-testing (HIVST) kits allowing 4,908 individuals to receive self-testing kits. • KPIF funding has supported the implementation of the COP 20 readiness plan which included an assessment and transition of 11 new clinical sites from CDC-supported partners to the EpiC/USAID project. A joint assessment (USAID, CDC, FHI 360 and MoH/PNLS) was conducted of new clinical sites that will be transitioned in COP20 to assess and identify gaps in services, HRH and equipment. Identified needs of those health facilities were considered in the COP20 and KPIF budget and subagreements. • In total, 13 Community Figure 15: Photo by FHI 360: The photo shows Executive Directors, District Based Organizations Directors and EpiC CI team posing after an annual partners coordination meeting. (CBOs), including three KP-led and 10 KP- competent CBOs benefited from KPIF funding in FY20. • Through the KPIF funding, EpiC was able to provide technical assistance to two local CBOs (BLETY and ASAPSU) that transitioned in FY20 for direct PEPFAR funding. The two CBOs received TA in assessing their HR systems and conducting a review of their HR manuals by an HR specialist from FHI360 HQ. A capacity development plan was developed for the two organizations and key program staff were trained on EPOA, Index testing and M&E systems, data quality assurance, and PEPFAR reporting.
D. Decentralized Drug Distribution implementation (DDD) In the Context of COVID-19, EpiC CI received headquarters bridge funds (HBF) to pilot Decentralized Drug Distribution (DDD) in six selected sites in Abidjan (primary priority) and seven sites that are supported by USAID/PEPFAR outside of Abidjan (second priority districts). The short-term plan as a response to COVID- 19 was to introduce and start implement three national distribution models including Community
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Adherence Group (CAG), outreach and use of Point of Distributions (PODI), and the private pharmacy model. EpiC CI was to assess the feasibility of implementing the private pharmacy models in selected areas of Abidjan. To achieve that, in Q4, EpiC CI conducted meetings with the MOH/PNLS and other stakeholders such as the National Pharmacists Council, health facilities in the targeted sites, and patients to engage them in the process, access the feasibility and acceptability of the DDD approach. The below tables provide preliminary data on the DDD acceptance by Private Pharmacies, Health facilities and patients.
Table 2: Acceptance of DDD strategy by the pharmacy
Acceptance of DDD strategy by the pharmacy N=104 % 1= Yes, unconditional 25 24% 2= Yes with some conditions 42 40% 9= No answer/neutral 7 7% Missing 30 29% Total 104 100%
Table 3: Acceptance of DDD strategy by the health facility
Acceptance of DDD strategy by the health facility N=71 % 0= No, Never 1 1% 1= Yes, unconditional 1 1% 2= Yes with some conditions 26 37% 8= Don’t know 1 1% 9= No answer/neutral 1 1% Missing 41 58% Grand Total 71 100%
Table 4: Acceptance of DDD strategy by the PLHIV Acceptance of DDD strategy by the PLHIV N= 96 % 0= No, Never 15 16% 1= Yes, unconditional 40 42% 2= Yes with some conditions 9 9% 9= No answer/neutral 9 9% Missing 23 24% Grand Total 96 100%
In light from the above tables, DDD acceptability as generally good with over 50% from patients and private pharmacies. Analysis of the collected data are ongoing and shall inform DDD programming and implementation in FY21
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E. Community-Led Monitoring EpiC CI also received HBF funding to support community-led monitoring (CLM). Key activities in Q4 included:
LINK: LINK captures an individual and community (group) feedback on the services receive from a social, legal or health providers, among others. In this reporting period, EpiC CI has finalized and test feedback collection survey tool (in French), established an online feedback reporting platform connected to the EpiC Online Reservation Application “ORA”. CBO staff from Alternative, Arc-En Ciel plus, and Espace Confiance were trained on the use of the LINK tool. Feedback collection can be done with phone, tablets or can be paper based. In FY21, the EpiC CI team will scale-up the training to other CBOs and its implementation in all project supported sites.
Community Score Cards: In Q4, program staff and KP members from the 13 EpiC supported CBOs were trained on how to facilitate community focus groups discussion (FGD), identify problems and propose solutions. In total, 38 outreach workers (PE, PN and supervisors) and KP members were trained. After the training, 12 FGDs were conducted in six sites supported by Espace Confiance, Alternative, Ruban Rouge and Arc En Ciel plus. Results from the FGDs show that KP members are satisfied with the health services they received in the EpiC CI referral sites (in Abidjan) and supported DICs. Common issues revealed by the participants of the 12 FGDs were repeated stockout of commodities, including condoms and water based lubricants. In FY21, Selected committee from the 12 FGDs will conduct interface meeting with district officials to discuss and address the identified challenge. EpiC CI is planning to scale- up feedback system in all supported sites in FY21 and will involve two national KP organization - ROPC – CI and DEKOTI – as well as existing partner Alternative CI, in addition to the PNLS.
Adverse Events Response: In Q4, KP members/peer educators, health care providers and other DIC staff were trained on KP safety and security, GBV prevention and responses including Adverse Events responses. In total, 32 participants were trained. After completing a Security Risk Assessment training, each of the 13 EpiC CI supported CBOs developed a safety and security plan.
F. Management and Operations • During this reporting period, EpiC CI and HQ team were involved in developing new subagreements for ASAPSU, CEEDEB, IDE Afrique, GBH, CSU Bardon, ROPC – CI, DEKOTI and modifications for ESPACE CONFIANCE, Alternative CI, Arc-en-Ciel, APROSAM, ORASUR, Femma Famille Solidarité SIDA, RSB, Ruban Rouge, ASD, FROMAGER SIDA Stop, SAPHARM, ENDA Santé and IDEAL Inter. • EpiC CI Annual Coordination workshop with CBOs and Districts: During this quarter, EpiC-CI organized a coordination workshop bringing together Executive Directors of CBOs, District Health Directors and EpiC CI team members to review the performance of FY20, review key challenges faced during implementation and identify solutions for those challenges to ensure a successful FY21. The workshop was conducted at Jacqueville from 29 to 30th September 2020. • GBV training: During this quarter, EpiC-CI conducted a five day training workshop on GBV. In total, 32 CBOs and KP members (15 PE, 15 PN and two staff from ROPC-CI and DEKOTI) were trained. The purpose of the training was to improve the GBV prevention and response .
G. Going Online to reach and engage KP in HIV Services During this reporting period, three CBOs were supported to implement online outreach activities, those include Espace Confiance, Alternative CI and AEC+. Eight (8) Online Peer Educators were trained on reaching KP online, providing social and behavior change communication (SBCC) messages and helping
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KP members access offline services including, social and health services, particularly HIV related services. In Q4, 137 individuals used the EpiC CI online reservation platform (known as “ N’Guan” meaning Health from a local dialect) to see appointments for HIV related services.
Figure 16: Overall Going Online Cascade
140
120 KPs Non KPs 51 100
80
60 36% 54% 15% 8 40 86 3 20 42 24 1 0 3 Booked appointments Arrived at clinic Tested for HIV HIV tested Positive online (N'Guan)
Figure 17 shows that among the 137 individuals who booked appointments online, 85% of those who were reached at the clinics were KP and only 8 were Non-KP. Of those who reached and received HIV testing service (27), four (4) we diagnosed with HIV (3 from the KP and 1 non-KP member). Of those who were reached at the clinic, 7 had STIs and received STI treatment. One individual tested negative and was linked to PrEP services and initiated PrEP. To launch the online platforms, EpiC CI hired a communication and marketing company to design vision elements and video content to post in order to attract KP members to visit program webpages including facebook and N’Guan “ORA”. A SOP was developed to guide the EpiC CI online program and Peer Educators who managed the online platforms were trained on KP tracking, online data analysis, and reporting. H. Priority Activities in the Next Three Months (October to December 2020) During the next three months in CI, EpiC will: • Issue new subagreements to all new clinical partners, two KPIF community engagement grants partners, and modifications of subawards to existing partners • Support CBOs to develop site level operational plans and do a post-award orientation on site • Support CBOs in filling the gaps regarding HRH, Equipment and upgrading services. • Provide ongoing technical support to accelerate activity implementation • Conduct various trainings with community and clinical partners • Secure MoUs with all Districts and Health Regions including other PEPFAR and GF partners • Open sub-offices in San-Pedro, Gagnoa and Bouaké and allocate staff to each of the offices • Finalize the purchase of three new vehicles for the three sub-offices • Onboard newly hired staff including a Senior Technical Advisor - Clinical Services, three Regional Site Coordinators, Program Officer, and a Communications Specialist • Collaborate with PNLS, CDC, USAID, and district health offices in auditing TX_CURR data in all the EpiC CI supported sites. • Ongoing RDQA
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Annex A: Performance Monitoring and Evaluation Matrix Achievements/Targets FSWs MSM Transgender PEPFAR Indicators (PEPFAR) Year Year Year support type FY20 % target FY20 % target FY20 % target Q4 to Q4 to Q4 to Target achieved Target achieved Target achieved Date Date Date KP_PREV: Number of KPs reached with individual and/or small group level HIV preventive interventions that DSD 2,672 13,132 9,222 142% 2,313 8,537 5,529 154% 3 149 354 42% are based on evidence and/or meet the minimum standards required HTS_TST: Number of KPs who received HIV Testing and Counseling (HTC) services for DSD 913 7,113 6,888 103% 1,015 5,092 3,708 137% 2 108 1,077 10% HIV and received their test results HTS_TST_POS: Number of KPs DSD 130 782 861 91% 189 704 556 127% 1 18 97 19% who tested HIV positive TX_NEW_VERIFY: Number of HIV-positive KPs confirmed as DSD 125 742 818 91% 189 690 528 131% 1 15 92 16% newly enrolled on antiretroviral therapy (ART)
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Annex B: Cumulative Performance by District for Key Indicators at Q4 Indicators
District KP_PREV HTS_TST HTS_TST_POS TX_NEW # Achieved # Achieved # Achieved Target % Target % Target % Target Total % Cumulative Cumulative Cumulative
Adjame_Plateau_Attecoube 2844 4392 154% 2730 2772 102% 327 289 88% 310 266 86% Anyama 433 725 167% 329 329 100% 44 45 102% 42 45 107% Cocody_Bingerville 1646 2886 175% 1172 1261 108% 164 171 104% 156 162 104% Koumassi_Port_Bouet_Vridi 1719 2017 117% 1258 1057 84% 167 143 86% 159 133 84% Treichville_Marcory 1295 1171 90% 967 601 62% 128 90 70% 122 85 70% Bouake_Nord_Ouest 1156 1324 115% 840 907 108% 111 103 93% 105 95 90% Divo 1033 1141 110% 756 621 82% 98 72 73% 93 70 75% Oume 571 1232 216% 415 477 115% 54 59 109% 51 59 116% Gagnoa 1083 991 92% 796 771 97% 103 109 106% 98 109 111% Katiola 0 485 NA 0 370 NA 0 40 NA 0 40 NA Korhogo 765 742 97% 563 574 102% 72 82 114% 68 82 121% Mankono 0 398 NA 0 259 NA 0 37 NA 0 37 NA San_Pedro 1312 1370 104% 947 714 75% 126 77 61% 120 77 64% Tabou 0 443 NA 0 360 NA 0 38 NA 0 38 NA Soubre 1248 1927 154% 900 835 93% 120 89 74% 114 89 78% Sassandra 0 574 NA 0 405 NA 0 60 NA 0 60 NA Total 15105 21818 144% 11673 12313 105% 1514 1504 99% 1438 1447 101%
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Annex C: Cumulative Performance by CBO for Key Indicators at Q4 Indicators
District KP_PREV HST_TST HTS_TST_POS TX_NEW # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative ESPACE_CONFIANCE 3,969 5,296 133% 2,946 2,466 84% 388 334 86% 369 314 85% ARC_EN_CIEL_PLUS 1,354 2,140 158% 1,618 1,556 96% 188 165 88% 179 156 87% RUBAN_ROUGE 1,490 2,252 151% 1,112 1,216 109% 139 124 89% 132 110 83% ALTERNATIVE_CI 1,124 1,503 134% 780 782 100% 115 115 100% 109 111 102% FAMILLE_FEMME_SOLIDARITE 0 574 NA 0 405 NA 0 60 NA 0 60 NA FROMAGER_SIDA_STOP 1,083 991 92% 796 771 97% 103 109 106% 98 109 111% APROSAM 1,312 1,813 138% 947 1,074 113% 126 115 91% 120 115 96% ASD 1,604 2,373 148% 1,171 1,098 94% 152 131 86% 144 129 90% ENDA_SANTE 1,156 1,324 115% 840 907 108% 111 103 93% 105 95 90% IDEAL_INTER 765 742 97% 563 574 102% 72 82 114% 68 82 121% ORASUR 1,248 1,927 154% 900 835 93% 120 89 74% 114 89 78% RSB_KATIOLA 0 485 NA 0 370 NA 0 40 NA 0 40 NA SAPHARM 0 398 NA 0 259 NA 0 37 NA 0 37 NA Total 15,105 21,818 144% 11,673 12,313 105% 1,514 1,504 99% 1,438 1,447 101%
Legend ≥ 90% between 75% 90% < 75%
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