COP18 PEPFAR Funding – COP18 Period: 1 October 2018 to 30 September 2019

Total Funding: $145,541,203 • testing, treatment (including drugs), DREAMS, prevention, laboratory, strategic information, HIV/TB, systems strengthening

• VMMC: $32,384,807 • OVC: $17,838,563 COP17 to COP18 – Reach 90% ART Coverage in all sub-populations

3 How the picture has changed in 10 years

2008 2018

4 A population level perspective of the HIV epidemic

5 2 years post-ZIMPHIA data collection: ZIMPHIA Where we stand NOW with progress towards epidemic control

Males 100% 78% 76% 73% 75% 62% 66% 53% 65% 57% 50% 25% 0% <15 15-24 25-49 50+ Total PLHIV Known Status On ART VLS

Females 94% 100% 85% 85% 80% 72% 75% 75% 58% 65% 50% 25% 0% <15 15-24 25-49 50+ Total PLHIV Known Status On ART VLS

6 Geographic ART coverage by end FY18, with absolute number of PLHIV left to find

7 2017 ART Coverage & Absolute Treatment Number Gap

Total Gap Total Abs District PLHIV All Ages F 15-19 M 15-19 F 20-24 M 20-24 F-25-29 M 25-29 F 30-49 M 30-49 F 50+ M 50+ (All Ages Number & Sexes) (All Ages & Sexes)

01 National 1,315,900 92% 86% 98% 71% 89% 88% 84% 70% 75% 66% 85% 201,302 222,000 76% 98% 83% 66% 101% 98% 82% 66% 57% 50% 79% 46,224 80,600 148% 112% 122% 94% 113% 103% 86% 74% 70% 67% 91% 7,412 34,730 69% 48% 93% 48% 176% 252% 53% 52% 51% 42% 73% 9,299 Hurungwe District 34,300 97% 85% 133% 96% 115% 134% 87% 81% 75% 63% 96% 1,426 District 33,290 75% 69% 98% 76% 143% 128% 82% 72% 88% 71% 90% 3,437 District 32,610 84% 112% 125% 89% 77% 98% 81% 75% 85% 76% 88% 3,940 District 32,080 78% 80% 84% 61% 94% 99% 98% 77% 86% 75% 92% 2,454 District 30,150 105% 87% 100% 71% 91% 92% 79% 61% 87% 70% 82% 5,353 District 28,160 173% 123% 184% 88% 135% 145% 104% 88% 58% 51% 105% -1,433 27,310 84% 57% 69% 36% 92% 51% 82% 68% 53% 65% 75% 6,861 26,100 95% 79% 107% 71% 76% 82% 79% 64% 71% 70% 81% 4,899 25,390 68% 71% 74% 61% 142% 177% 78% 73% 65% 50% 87% 3,423 Murewa District 24,330 119% 86% 76% 43% 73% 61% 64% 55% 66% 61% 68% 7,715 23,130 91% 72% 118% 91% 223% 262% 67% 63% 86% 83% 95% 1,054 23,100 93% 70% 75% 52% 67% 61% 68% 49% 102% 77% 72% 6,437 District 22,800 74% 52% 100% 86% 143% 150% 68% 49% 65% 47% 75% 5,736 District 22,640 174% 177% 117% 107% 98% 99% 81% 56% 60% 69% 83% 3,756 22,620 78% 71% 93% 105% 150% 145% 87% 81% 95% 72% 98% 441 District 20,390 116% 99% 100% 97% 96% 141% 95% 69% 95% 83% 96% 744 19,630 95% 77% 100% 78% 163% 165% 45% 38% 60% 43% 71% 5,682 18,980 81% 133% 83% 44% 87% 79% 75% 52% 97% 67% 79% 3,936 18,330 118% 93% 78% 32% 170% 139% 68% 44% 131% 105% 91% 1,732 District 18,080 143% 164% 117% 124% 241% 241% 86% 79% 128% 146% 122% -4,027 18,030 135% 112% 202% 186% 142% 154% 106% 94% 97% 79% 120% -3,565 District 18,000 61% 63% 90% 60% 103% 85% 98% 70% 96% 63% 89% 1,931 16,150 97% 112% 160% 78% 193% 141% 68% 49% 90% 100% 93% 1,084 14,850 86% 63% 96% 41% 108% 91% 65% 46% 77% 59% 74% 3,915 14,150 111% 121% 94% 45% 113% 101% 98% 65% 147% 95% 102% -229 14,050 128% 113% 112% 71% 109% 108% 94% 71% 122% 84% 101% -141 13,540 103% 111% 74% 46% 65% 63% 86% 94% 140% 139% 99% 108 13,380 51% 38% 53% 36% 60% 70% 50% 53% 87% 81% 60% 5,312 District 13,090 86% 62% 98% 56% 105% 86% 83% 71% 90% 66% 87% 1,696 12,870 169% 124% 237% 185% 213% 235% 111% 105% 129% 73% 139% -4,978 12,540 110% 71% 129% 102% 196% 220% 78% 72% 93% 70% 99% 145 Nkayi District 12,490 94% 89% 92% 42% 115% 117% 65% 58% 109% 120% 86% 1,739 12,230 85% 81% 98% 38% 121% 85% 81% 57% 99% 82% 88% 1,525 11,970 67% 97% 82% 45% 127% 133% 96% 87% 116% 122% 105% -599 District 11,160 118% 73% 112% 43% 85% 53% 58% 55% 122% 72% 74% 2,871 10,830 77% 87% 109% 86% 90% 117% 85% 68% 64% 47% 86% 1,566 9,900 58% 40% 62% 21% 81% 74% 59% 54% 81% 78% 67% 3,277 Proportion of National ART patients supported by PEPFAR

1,200,000 83% 90% 80% 1,000,000 73% 70% 800,000 60% 50% 600,000 38% increase in patients 40% supported in 400,000 12mos 30% 20% 200,000 10% - 0% 2016 2017 PEPFAR MOHCC Trajectory towards 95-95-95

1,600,000 1,437,629 1,400,000 1,338,826

1,200,000 1,136,503

1,000,000

800,000

600,000

400,000

200,000

- PLHIV Current on ART National Target PEPFAR Target 10 Traditionally siloed HTC models vs. an Integrated HTS model

An integrated HIV testing model:

Self-testing leveraged 1. PITC & CITC across all steps

2. Index Testing & Contact Tracing

3. Targeted outreach for those not coming to facilities All together: High yield in Index Testing—High volumes with PITC

FY18Q1 Modality: contribution to positives (yield) % Yield by Modality Facility Index: 0.11% (33%) Comm. Index: 7% (40%) Targeted Mobile: 3% (15%) PITC: 89% (5%) Facility VCT: 0.6% (14%) Comm. VCT: 0.6% (12%)

We need all of the modalities in the: % HIV_POS by Modality • Right place • Right time • Right sub-population

12 We are not letting up: Still Finding HTS_POS in High ART Coverage Districts

1200 120%

115% 1000 115%

111%

800 110%

600 105% Number HTS_POS 400 99% 99% 100%

200 95%

0 90% Buhera Chegutu Makonde Mangwe Districts

FY17 Q2 FY17 Q3 FY17 Q4 FY18Q1 ART coverage

13 And where we are not performing we are intensifying efforts in facilities

Improvement in 7 Harare Sites with intensified PITC • HIV tests average weekly increase from 399 to 2207 • HTS_POS average weekly increase from 28 to 128 • 80% of positives were linked to ART

14 And maximizing community platforms: finding positives through Sexual Network Testing

• 8 HIV+ identified • 7 initiated on ART • Ages 22-55 yrs • 4 weeks • 128km covered

15 Where are men being diagnosed?

16 What have we learned? → So what are we doing? Interagency learning & collaboration allows us to more rapidly apply successful approaches

• Leveraging the facility platform → scaling up iPITC model • Index testing works → expanding index testing model • Targeted Mobile Testing finds people who won’t come to facilities → using this strategically • Self testing could be a game changer → scaling it up

17 PEPFAR Zimbabwe integrated HIV Testing Model (iHTS)

Maximizing successful strategies to find sub-populations

MoHCC Health Facilities • Verbal screening and routine testing • HRH & technical assistance

Facilities Support Client Initiated Testing (VCT) • Client options: (1) Self-testing; (2) Conventional provider delivered HTC • Key population friendly

Index Testing Facility Community • Written invitation sent home • F/u with phone call & home visit • Test return clients • Test sexual partners & at-risk HIV Self-Testing • F/u non-return in Community children • Used strategically in all modalities • PEPFAR procured kits & leverage UNITAID Kits

Targeted Community Outreach Contact Tracing • Based on sub-population need • Trace sexual partners in community • Prioritize geographic areas & off hours • Test sexual partners & at-risk children National

46,224 PLHIV Gap 3,000-10,000 PLHIV Gap Adjust the intensity of PEPFAR support & Harare 17 Districts testing modalities to reach 95-95-95 by district & by sub-population

High ART Gap High ART Gap

1,500—3,000 PLHIV Gap <1,500 PLHIV Gap 8 Districts 7 Districts 0 PLHIV Gap 7 Districts

Maintenance

Medium ART Gap Low ART Gap Transition of HTS program inputs from High ART Gap districts to no-ART gap districts

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Case-based 0% surveillance High Medium Low No Gap (>9,500) (3,000-9,499) (1-2,999) Facility-based Testing w/HRH TA only Facility-based Testing Facility Index Community-based testing Comm Index Community-based testing Outreach Transition of HTS program inputs from High ART Gap districts to no-ART gap districts

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Case-based 0% surveillance High Medium Low No Gap (>9,500) (3,000-9,499) (1-2,999) Facility-based Testing w/HRH TA only Facility-based Testing Facility Index Community-based testing Comm Index Community-based testing Outreach Linking all HIV+ to treatment and care

Zimbabwe adopted Treat All in 2016 Expanding differentiated models of care OVC partner and health facility linkages

23 As we reach 95-95-95: linkage is improving & yield is declining

FY16 Q1: 54% Linkage & 8% yield FY18 Q1:74% Linkage & 6% yield

24 Community ART Initiation Increases Linkage

1200 100% 89% ART initiation rate: 89% Introduction of community ART 90% 1000 80%

70% 800 60%

600 50%

40% 400

Number of individuals of Number 30% Proportion initiated on ART on initiated Proportion 20% 200 10%

0 0% Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Tested HIV Positive Initiated on ART ART Initiation Rate

25 New on ART and Adhering to Treatment

Differentiated Models of Care Multi-month Scripting & Dispensing Community & Family Refill Groups

26

Leveraging Community Presence: Defaulter Tracking

October 2016—September 2017 October 2017—December 2017 • Total defaulters identified: 9,707 • Total defaulters identified: 1,357 • Total in care: 8,348 (86%) • Total in care: 1,263 (93%) • Returned to care: 5,630 (58%) • Returned to care: 1,099 (81%) • Still in care: 2,718 (28%) • Still in care: 164 (12%) 1% 3% 3% 6% 3% 4% 7% 6%

10%

28% 58% Improved 81% 18% collaboration & documentation

2828 Differentiated Models of Care to Keep People on Treatment

CARGs • Groups: 5,389 • Individuals: 43,770 • Quarterly ART refills • 39% received VL test (n=7,923) • 95% virally suppressed CATS • CATS: 885 • Support groups: 525 • Adolescents in support groups: 14,189

29 Viral Load Scale-up

30 Viral Load

National Commitment to ensure Viral Load is accessible National Viral Load Scale up Plan Integrated Sample Transport

31 Viral Load Scale Up: Working together to Achieve 40% National Coverage

National VL Testing Targets 2017 - 2020 Fiscal Year 2017 2018 2019 2020

National ART Patient Targets 1,054,228 1,087,412 1,102,930 1,117,734 (GF based on this) Viral Load Implementation Targets 40% 60% 80% 90% Viral Load Test Targets 421,691 652,477 884,744 1,005,960

Revised ART Patient Targets 1,061,574 1,164,598 1,293,866 1,293,866* (Estimated based on actual and target pts on ART)

VL test targets 424,630 698,759 1,035,093 1,164,479 (based on revised denominator) *Assume will maintain 90% coverage in FY20 but don’t have a PLHIV estimate to estimate this figure. • Initial rollout of VL Testing in 2015 slower than planned. Achieved roughly 14% coverage in 2016. • MOHCC updated timeline and targets • Target to achieve > 90% coverage by December 2020

32 We are strengthening systems to ensure viral load monitoring translates to better clinical outcomes GIS Mapping and integrated specimen transport to reduce turnaround time

Lab Information Management System using data for decision making VMMC

34 35 VMMC: efficiencies in coverage

• COP 17: $35 million COP 18: $31.8 million • Target: 306K Target: 306K Cost per circumcision: $113.25 Cost per circumcision: $103.85 (8.3% reduction)

350000 Quarterly progress towards targets

300000 11 250000 districts 25548 60%+

200000 coverage 31691 259917 150000 306154 23 100000 Remainin g districts 50000

0 COP15 COP16 COP17 COP18

Q1 Q2 Q3 Q4 gap to target AGYW

37 Where are we finding AGYW?

38 DREAMS and PrEP

Zimbabwe is a model for other DREAMS countries

39 DREAMS Zimbabwe

4040 FY18 Q1 – 64% of AGYW (10-24yrs) layering 3 or more services

% AGYW 10-24 Receiving 1 or More Services (N=287,202) % AGYW 10-24 Receiving Different Number of Services, by Age Group

15% 20 - 24

35%

21% 15 - 19

10 - 14 29%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 1 2 3 4 or more 1 service 2 services 3 services 4+

41 DREAMS: an updated vision for COP18

Maintain services for the most Identify efficiencies & Scale up focus on AG 9-14 vulnerable AGYW 15-24 transition when appropriate

Develop age appropriate risk Implement a more holistic, but highly targeted Institute maintenance package for secondary avoidance/violence prevention program for approach for most vulnerable AGYW 15-24 school CSE program younger AG

Continue focus on this age group in secondary OVC, out of school girls, YWSS, teen/single Transition out of cash transfers, but maintain schools & expand to primary mothers, economically vulnerable educational subsidies & expand to 12-14s

Leverage OVC program to expand depth & Continue support for post violence care, PrEP, Streamline implementation arrangements to variety of services to AG 9-14 FP outreach, access to HTS and STI services improve efficiencies, including targeting using most appropriate modalities

Continue community norms work but update Improve alignment with OVC program so all focus on sexual violence prevention & risk Continue active linkage of HIV+ AGYW to CATS female OVC in DREAMS districts access the avoidance for younger AG DREAMS package

\ 42 Children and OVC

43 New & Intensified Cascade strategies for OVC & Peds

• Strengthen & decentralize EID • Mentoring to improve confidence/knowledge on • Invitational Index from • Treatment literacy and poor pediatric ART initiation and HIV+ Mother reliability of self-reported management • adherence iPITC • HRH to ensure coordination • Targetting male patients and • HIV Risk Assessment tool with OVC partners those with male caregivers • Identify high risk Mothers - • Treatment literacy and poor (more likely to show virologic HEI reliability of self-reported failure) adherence • CATS employ Index Model • EID/VL turnaround time • Male patients and those with • Disclosure/stigma male caregivers more likely • Zvandiri (CATS support) model to show virologic failure addressing both patient and caregiver needs Tested On ART Retained & Adherent How we are expanding OVC services in COP18 Prioritizing services for specific sub-population

Standard OVC package +

Children living with HIV • Adherence support (link with Africaid CATS) • Early childhood stimulation & nutrition (0-4) within HIV platforms such as PMTCT • Disclosure support for children & caregivers

Children of Key Populations • Link with PSI providing services to KP • HTS, treatment & care; included in differentiated care models • Educational subsidies, economic strengthening • Age-appropriate disclosure, counseling & support for caregivers & children

45 Key and Vulnerable Populations

46 Targeted approach to KP programming in the 5 largest urban areas

• PSI • Direct service delivery • Public sector component in 4 districts • Above site level TA to MOHCC & NAC • Sub-partners: CeSHHAR FSW, SRC, GALZ, Hands of Hope (new) • ITECH • Public sector component in 1 district • Training & material development • Sub-partner: PZAT

47 Key Populations COP18 Vision: Leveraging with GFATM PEPFAR Global Fund

• Saturation of 5 KP locations: PEs, outreach • 30 total FSW sites (10 static); previously funded clinics, filling staffing gaps by UNFPA • Special focus on young women selling sex • PrEP provision in SW clinics (DREAMS) • Significant funding for PrEP drugs for FSW only • Support of NSCs for KP service delivery • Support for FSW & MSM PEs but insufficient for • MSM Enhanced peer models all sites • Support transitioning of KP services to public • 6 MSM drop in centers: Harare, Mutare, Karoi, sector Bulawayo, Masvingo & Gweru • National level TA for M&E, joint • No service delivery for MSM or PrEP strategy/planning, standardized tools & materials • Some funding for capacity building of CSOs • National & district level coordination, including 2 • No funding for TSU shared secondments

48 Commodities

50 2018 – 2020 Projected National First Line ARV Stock Status

51 Health Systems– Gaps & Solutions

• Supply Chain Management • EHR • Laboratory Services in • LIMS support of Viral Load Scale- • DHIS2 (National, up DREAMS, KP) • Civil Society ART Monitoring Systems HSS and technology

Coordination Data and Quality Management • MOHCC Secondments • EQA • HTS/Tx Literacy • Institutionalized DQRS coordination with FBO & CBOs

54 Preliminary results from FY18 Q3

Indicator FY18 FY18 FY17 Q1 FY17 Q2 FY17 Q3 FY17 Q4 FY18 Q1 FY18 Q2 FY18 Q3Results Cum. FY18 Target Results Results Results Results Results Results Cumm % Results

HTS_TST 534,987 706,214 581,746 668,066 662,257 743,741 684,015 2,090,013 2,694,369 77.6% l

HTS_TST_POS 40,196 45,713 36,742 40,298 39,796 41,360 34,341 115,497 288,844 40.0% l

Overall Yield 8% 6% 6% 6% 6% 6% 5% 5.5% 11% 5.5%

TX_NEW 28,687 37,669 29,118 33,500 30,449 32,985 28,326 91,760 269,315 34.0% l

Proxy Linkage 71% 82% 79% 83% 77% 79% 82% 79% 95% 79% TX_CURR 688,142 732,870 759,149 848,120 923,988 939,033 958,283 958,283 984,129 97.3% l

TX_NET_NEW (48,943) 44,728 26,279 88,971 75,868 14,069 19,250 109,187 136,009 80.1% l

VMMC_CIRC 38,891 48,271 61,714 78,423 49,603 54,079 78,774 182,456 306,144 59.6% l

57 All testing strategies yield stabilizing or going down; Are we doing the same thing over time or lax in strategy 35,000 50% 46% 45% 43% 45% 30,000 41% 40%

40% Testing HIV Yield (%) 25,000 35% 30% 30% 20,000 25% 26% 25% 15,000 20% 13% 13% 15% 10,000 12% 11% 11% 10% 8% 10% 5,000 5% 5% 5% 5% 0% 1% 0%

0 0%

Number NewlyDiagnosed HIV+

FY18Q3 FY18Q1 FY18Q1 FY18Q2 FY18Q1 FY18Q2 FY18Q3 FY18Q1 FY18Q2 FY18Q3 FY18Q1 FY18Q2 FY18Q3 FY18Q1 FY18Q2 FY18Q3 FY18Q2 FY18Q3 FY18Q1 FY18Q2 FY18Q3 Comm Index Comm Mobile Comm VCT Facility Index Facility PITC Facility VCT Facility VMMC Positive %Yield Thank you

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