Epidemiology and Policy Summary South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only What Does it Take to “Eliminate HIV”?

• Utilize Underlying Population Data • Triangulate Program Data • Ensure a Supportive Policy Environment • Shift the Program for Impact • Intensify Partner Management

2 South Africa: Decreasing Incidence, Increasing Treatment

8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Total HIV infections Cumulative AIDS deaths Total number of ART patients Total new HIV infections Total new on Treatment

3 South Africa: Same Trend Where It Matters Most

KwaZulu Natal Gauteng 2,000,000 2,000,000

1,800,000 1,800,000

1,600,000 1,600,000

1,400,000 1,400,000

1,200,000 1,200,000

1,000,000 1,000,000

800,000 800,000

600,000 600,000

400,000 400,000

200,000 200,000

0 0

Total HIV infections Total AIDS deaths Total HIV infections Total AIDS deaths Total new HIV infections Total number of ART patients Total new HIV infections Total number of ART patients Total new on Treatment Total new on Treatment

4 Clinical Cascade

1st 90*

2nd 90*

3rd 90**

*Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694] **NHLS program data Oct 2017

5 South Africa: Burden of HIV by Sex

6 Provincial HIV Burden: Highest-Burden Provinces

PLHIV Gauteng 2017 Male Female Male PLHIV KwaZulu-Natal 2017 Female

Age Group Age Group

7 Clinical Cascade by Sex

Adult Women Adult Men

1st 90*

2nd 90*

PLHIV PLHIV = = 4 471 347* 2 542 120* 3rd 90**

F 15- F 15-24 F 15-24 24 F 15-24 15% 14% M 25+ 19% 18% M 25+ M 25+ Distribution of 41% M 25+ 43% 40% coverage gap 46% 90% F 25+ F 25+ F 25+ F 25+ 33% 34% 27% 39% 80%

70%

60%

50%

% PLHIV on ART on % PLHIV 40%

30%

20%

10%

0% <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ M F M F M F M F

gp City of Johannesburg gp City of Tshwane Metropolitan gp Ekurhuleni Metropolitan kz eThekwini Metropolitan 9 Metropolitan Municipality Municipality Municipality Municipality Political Requirements for a Supportive Policy Environment

POLICY STATUS

Self Screening Working with Government of South Africa Approval to fast-track approval (April)

PrEP Final policy in place (AGYW to start in April)

Same-Day Initiation Policy in place, reminder circular out

Differentiated Care Policy in place; discussing improvements to National Adherence Guidelines

UID/IUD Policy in place, implementation varied

TRAP Weekly facility review in practice

POLICY STATUS

HRH Policy Task force for monitoring and policy needed

CHW Policy Initiated but not complete, to include SOW, Remuneration, Sustainability

Community ART Initiation No policy

10 FY2018 Quarter One Performance South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only Our Performance is Not on Track

FY2017 Q1 FY2017 Q2 FY2017 Q3 FY2017 Q4 FY2017 APR FY2017 TARGET % Achievement HTS_TST FY2017 2,456,092 Q1 FY2017 2,567,085 Q2 FY2017 2,870,112 Q3 FY2017 2,778,479 Q4 FY2017 10,671,768FY2018 APR FY2017 Q1 5,767,766 TARGETFY18 TARGET% Achievement185%% HTS_TSTHTS_TST_POS 2,456,092 221,892 2,567,085 234,127 2,870,112 241,300 2,778,479 223,025 10,671,768 920,344 2,282,560 5,767,766 839,648 10,026,497 185%110%23% HTS_TST_POSHTS Yield 221,8929.0% 234,1279.1% 241,3008.4% 223,0258.0% 920,344 8.6% 181,486 839,648 14.6% 977,545 110%19% HTSTX-NEW Yield 183,9579.0% 191,3059.1% 155,6468.4% 163,8168.0% 694,724 8.6% 8% 965,13114.6% 10% 82%72% TX-NEWLinkage 183,95783% 191,30582% 155,64665% 163,81673% 694,724 75% 143,187 965,131 115% 1,032,601 14%72% LinkageTX_CURR 2,950,89483% 3,040,02182% 3,157,13765% 3,157,96573% 3,157,96575% 79% 3,935,927115% 106% 75%80% TX_CURRTX_NET_NEW 2,950,894 235,131 3,040,021 89,127 3,157,137 117,116 3,157,965 828 3,157,965 442,202 3,221,849 3,935,9271,220,164 4,362,429 74%80%36% TX_NET_NEWTX_RET 235,131 89,127 117,116 82870% 442,202 70% 63,884 1,220,16490% #VALUE!36%78% TX_RETTX_PVLS 70%85% 70%85% 90%91% 78%93% TX_PVLSVMMC_CIRC 44,626 47,280 158,791 189,95085% 440,647 85% 61,503 393,465 91% 570,879 112%11%93% VMMC_CIRCPrEP_NEW 44,626 304 47,280 381 158,791 698 189,950 768 440,647 2,151 724 393,465 1,279 18,171 112%168%4% PrEP_NEWKP_PREV 304 116,930 381 698 71,115 768 188,045 2,151 61,503 109,385 1,279 570,879 168%172%11% KP_PREVPP_PREV 116,930343,849 752,441 71,115 1,096,290 188,045 109,385579,323 172%189% PP_PREVOVC_SERV 343,849442,200 752,441762,304 1,096,290 799,820 724 579,323664,521 18,171 189%120%4% OVC_SERV 442,200 762,304 799,820 664,521 120% • PEPFAR SA is not on track for Case finding, Treatment initiation, and Treatment retention

• VMMC is currently in the low season and is on track to meet FY18 targets; FY18 Q1 results out-perform FY17Q1.

• PrEP is expected to accelerate with the launch of AGYW programming in April 2018.

12 We are Monitoring Case Finding on a Weekly Basis

We are monitoring yield optimization in real time HTS_POS case identification 1800

1600 eThekwini MM

1400 Ekurhuleni

1200 gp City of Johannesburg 1000

gp City of Tshwane 800

600

400

200

13 Proxy Linkage Doesn’t Match New on Treatment

FY18 Q1 Partner TX_NEW Proxy Linkage, facility Outlay

Anova Health Institute (17020) 33% 93% 24%

Right To Care, South Africa (17021) 19% 79% 27%

Broadreach (17023) 14% 101% 19%

Foundation for Professional Development (17036) 8% 84% 19%

Wits Reproductive Health& HIV Institute (17037) 27% 109% 27%

MatCH (17038) 17% 101% 28%

Kheth'Impilo (17046) 9% 105% 20%

Health Systems Trust (18481) 13% 84% 13%

TB/HIV Care (18482) 8% 97% 17%

Aurum (18484) 13% 89% 21%

14 Enhanced Monitoring for Partner Management: Direct Linkage to ART

PEPFAR SA HTS providers are required to link to ART (and we are tracking it) • Beginning FY18, partners reporting HTS data also report Direct linkage indicator: HTS_TST_ART 14-day ART initiation outcomes among clients who HTS_TST Numerator: # clients who initiate ART ≤14 days of HIV diagnosis test positive (HTS_TST_ART) HTS_TST_POS

Denominator: HTS_TST_POS • As a testing program metric, this indicator places HTS_TST_ART Disaggregations: Age; Sex; accountability for linking Modality (Community/Facility) clients to ART directly with HTS providers

15 New Direct Linkage Indicator Partner Management Action

ART initiation <14 days following positive HIV test result Example: Facility HTS_TST_ART results, FY18 Q1, by age/sex

Facility Proxy linkage

TX_NEW/ HTS_TST_POS

Facility Direct linkage

HTS_TST_ART/ HTS_TST_POS

Directly measured 14-day ART initiation outcome, as reported by HTS partner

16 Unique Patient Identifiers: On Track to 80% Coverage in FY18

UID completeness as % of TROA 90% Need to drive UID in priority districts 84% 80% 74% 74% 68% 70% 66% 61% 59% 58% 60% 55% 50% 50% 45% 46% 42% 40% 37% 40% 35% 35% 33% 30% 29% 30%

20%

10%

Based on partner reports, January 2018.

17 TX_NEW FY16-FY18 Q1, 27 Focus Districts and 4 Highest-Burden Districts

27 Focus Districts combined 4 Highest-Burden Districts

250,000 35,000 UTT re-set the baseline, but we need to do more 30,000 200,000

25,000

150,000 20,000

15,000 100,000

10,000

50,000 5,000

- 0 FY16-Q1 FY16-Q2 FY16-Q3 FY16-Q4 FY17-Q1 FY17-Q2 FY17-Q3 FY17-Q4 FY18-Q1 FY16-Q1 FY16-Q2 FY16-Q3 FY16-Q4 FY17-Q1 FY17-Q2 FY17-Q3 FY17-Q4 FY18-Q1 Jul-Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Oct-Dec '16 Jan-Mar '17 Apr-Jun '17 Jul-Sep '17 Oct-Dec '17 Jul-Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Oct-Dec '16 Jan-Mar '17 Apr-Jun '17 Jul-Sep '17 Oct-Dec '17

gp City of Johannesburg Metro gp Ekurhuleni Metro kz eThekwini Metro 18 VMMC Weekly Trend Analysis – Through February 16, 2018

12000 10,787 Ramping up for high season

10000

8000 Weekly Target 7,420 6,889 6,260 6,279 6000 5,392 5,433

4,244 4,137 4,145 4,369 4000 2,863 1,820 1,961 2000 1,510

1/1/2018 1/3/2018 1/5/2018 1/7/2018 1/9/2018 2/2/2018 2/4/2018 2/6/2018 2/8/2018

11/6/2017 11/8/2017 12/2/2017 12/4/2017 12/6/2017 12/8/2017 1/11/2018 1/13/2018 1/15/2018 1/17/2018 1/19/2018 1/21/2018 1/23/2018 1/25/2018 1/27/2018 1/29/2018 1/31/2018 2/10/2018 2/12/2018

11/10/2017 11/12/2017 11/14/2017 11/16/2017 11/18/2017 11/20/2017 11/22/2017 11/24/2017 11/26/2017 11/28/2017 11/30/2017 12/10/2017 12/12/2017 12/14/2017 12/16/2017 12/18/2017 12/20/2017 12/22/2017 12/24/2017 12/26/2017 12/28/2017 12/30/2017 November December January February

19 PrEP Trend by Sub-Population (SW and MSM)

We will continue acceleration in SW and MSM; AGYW to begin in April 2018 to get us

600 on track for annual PrEP targets

500

400

PrEP_NEW MSM 300 PrEP_NEW TG PrEP_NEW FSW

200

100

0 2 3 1 0 0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017 Oct to Dec 2017

20 Maximize TB Entry Points, including TB Suspects, for Case Identification

TB-HIV CLINICAL CASCADE FY2017

180,000

160,000 96% know their status 140,000 66% are positive

120,000 93% are on ART 100,000

80,000

60,000

40,000

20,000

0 TB_STAT TB_STAT TB_STAT Pos TB_ART D N N N

21 COP 2018 Vision South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only Civil Society Recommendations

• Substantial Expansion of Community Healthcare Worker program to optimize impact and community linkages • Increase of Health Workers providing direct service delivery, including nursing services • Expansion of access to PrEP for FSW, MSM, AGYW to support South Africa government program • Expanded adherence clubs and support groups • Roll-out of self screening, including through CHWs • Broad implementation of DBE school CSE program

23 COP18 Top-Line Targets: Care and Treatment

SURGE SURGE+ (public + private) Indicator 52 Districts 27 Focus Districts 4 Highest-Burden Indicator 52 Districts 27 Focus Districts 4 Highest-Burden Districts* Districts* PLHIV (FY19) 7,424,087 6,017,094 2,295,453 PLHIV (FY19) 7,424,087 6,017,094 2,295,453 CLHIV (FY19) 292,295 236,975 91,818 CLHIV (FY19) 292,295 236,975 91,818 HTS (adult) 10,155,519 8,318,664 2,921,693 HTS (adult) 11,170,902 9,150,530 3,283,983 HTS_pos (adult) 925,334 809,826 365,063 HTS_pos (adult) 1,017,867 890,809 410,331 HTS (children) 1,320,473 1,236,040 512,316 HTS (children) 1,452,520 1,359,644 575,843 HTS_pos (children) 100,249 91,809 39,902 HTS_pos (children) 110,274 100,990 44,850 TX_NEW 1,163,857 1,014,692 445,398 TX_NEW 1,280,243 1,116,161 500,627 TX_CURR (all) 5,565,459 4,557,948 1,859,317 TX_CURR (all) 6,122,005 5,013,743 2,089,872 TX_CURR (<15) 286,621 242,859 91,818 TX_CURR (<15) 315,283 267,145 103,203 TB_PREV 578,257 578257 170,570 TB_PREV 578,257 578,257 170,570 *Assumes 10% of overall HTS and TX services are provided via the private sector (11.0% in 27 focus districts; 12.5% in 4 highest-burden districts).

*TX_CURR targeted to 5.5 million to better align to SURGE targets **Include eThekwini, Tshwane, Johannesburg, and Ekurhuleni

24 COP18 Top-Line Targets: Prevention

SURGE Indicator 52 Districts 27 Focus Districts 4 Highest-Burden Districts* PLHIV (FY19) 7,424,087 6,017,094 2,295,453 CLHIV (FY19) 292,295 236,975 91,818 VMMC 510,489 497,638 178,428 VMMC (15-34) 425,268 414,587 148,088 OVC_SERV 626,604 626,604 317,054 PP_PREV 689,067 689,067 419,769 KP_PREV 184,561 153,733 90,051

*Include eThekwini, Tshwane, Johannesburg, and Ekurhuleni

25 Surging to Saturation in All Focus Districts

26 COP18 FAST: Balanced and Earmark Achieved

27 COP18 Total Funding – An Investment in DSD

28 Core Program South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only Core Solutions: Evidence-Driven and Taking to Scale

Community • Index to Scale • Community-Facility Handshake to Ensure Linkage • Improve National Adherence Guidelines • LTFU SOP • Community Health Workers

Facility

• Optimize PITC including Presumptive TB Cases • Same-Day Initiation • Routine Site-Level Cascade Analysis • Unique ID, Data Quality and Use • Clinic Lab Interface • Pharmacy

Above-Site • Provincial Data Centers • Supply Chain • Human Resources Information System • Enhance Laboratory System

Collaboration • Aligned with NSP • Leveraging Global Fund Investments • PFIP

30 The National Clinical Cascade 1st 90* • Focused, high-yield testing modalities • Index Testing

2nd 90* • Stronger community-facility linkage (retention, back to care) • Same-day initiation • Direct linkage monitoring 3rd 90** • Stronger community-facility linkage (retention, back to care) • NHLS-TIER.Net integration • UID

31 Problem: Poor Case Finding (FY18 Q1)

32 Index Testing Works – High Yield

33 Solution: We are Scaling Index Testing and PITC

Community Focused Home/Hotspot Community Index

Community Mobile

Community Other

Facility Index

Facility Inpatient/Peds Facility PITC

Facility VCT

FY18 (COP17) Facility VMMC

PITC-based testing in SA is primarily supported by SA government. FY19 (COP18)

34 Problem: Linkage Needs to be 100%

FY18 Q1 Achievement by DSP, 27 focus districts

FY18 Q1 Proxy Linkage, FY18 Q1 Partner HTS_TST HTS_TST_POS TX_NEW Outlay facility Outlay

Anova Health Institute (17020) 55% 67% 24%33% 93% 24% Right To Care, South Africa (17021) 25% 20% 27%19% 79% 27% Broadreach (17023) 25% 19% 19%14% 101% 19% Foundation for Professional Development (17036) 21% 18% 19%8% 84% 19% Wits Reproductive Health& HIV Institute (17037) 23% 25% 27%27% 109% 27%

MatCH (17038) 26% 26% 28%17% 101% 28% Kheth'Impilo (17046) 14% 12% 20%9% 105% 20% Health Systems Trust (18481) 16% 16% 13%13% 84% 13% TB/HIV Care (18482) 25% 11% 17%8% 97% 17% Aurum (18484) 21% 16% 21%13% 89% 21%

35 Solution: New Indicator to Monitor Direct Linkage and Act 4 Highest-Burden Districts: FY17 Community Monthly Linkage Achievement* 2500 180% 155% 160%

2000 140%

120% 1500 95% 92% 100%

Number of HTS_POS 63% 80% 1000 54% 57% Linkage 45% 60% 40% 38% 33% 40% 500 21% 23% 20%

0 0% OCT_17 NOV_17 DEC_17 OCT_17 NOV_17 DEC_17 OCT_17 NOV_17 DEC_17 OCT_17 NOV_17 DEC_17 gp City of Johannesburg Metropolitan gp City of Tshwane Metropolitan gp Ekurhuleni Metropolitan Municipality kz eThekwini Metropolitan Municipality Municipality Municipality

*linked to TIER.net 36 Solution: DSD Works to Increase Same-Day Initiation

140 25 strategically placed nurses increased same-day initiation by 120 39% in highest-volume sites in Ekurhuleni 100 80 60 40 20 0

Q4 2017 Q1 2018

37 Problem: Retention is Low

Partner Districts Anova lp Mopani 17021 17023 17046 16584/184 13797/ gp City of Johannesburg 17020 (Right to (BroadRea 17036 17037 17038 (Kheth'Imp 84 18481 18482 Right to gp City of Johannesburg INDICATOR (Anova) Care) ch) (FPD)) (WRHI) (MATCH) ilo) (Aurum) (HST) (THCA) Care mp Ehlanzeni fs Thabo Mofutsanyane HST_TST 288% 180% 242% 184% 214% 143% 770% 160% 211% 277% Broad kz Harry Gwala Reach kz Ugu kz King Cetshwayo HTS_POS 154% 121% 181% 111% 226% 89% 1084% 131% 113% 26% ec Alfred Nzo mp Gert Sibande TX_NEW 84% 75% 99% 39% 60% 63% 269% 96% 80% 47% gp Sedibeng gp Ekurhuleni nw NMM TX_CURR 103% 88% 80% 86% 73% 77% 93% 77% 83% 68% nw Bojanala Platinum FPD ec Buffalo City NET_NEW 115% 48% 34% 62% 20% 29% 56% 32% 40% 10% lp Capricorn gp City of Tshwane mp Nkangala TX_RET (N/D) 80% 72% 66% 65% 99% 74% 73% 74% 78% 78% WRHI nw DKK gp City of Johannesburg TX_PVLS (N/D) 89% 90% NA 87% 88% 94% 93% 84% 76% 76% Match kz eThekwini KI wc City of Cape Town VMMC NA NA NA NA NA NA NA 65% NA 113% kz uMgungundlovu Aurum gp Ekurhuleni PMTCT_STAT (N/D) 97% 101% 99% 97% 99% 99% 98% 93% 98% 96% nw Bojanala Platinum Nw NMM PMTCT_ART (N/D) 98% 99% 92% 99% 97% 99% 99% 96% 97% 91% HST fs Lejweleputswa ec OR Tambo ec Chris Hani Outlay 173% 152% 110% 85% 124% 148% 112% 86% 83% kz Zululand kz eThekwini >90% 80-90% 70-80% <70% kz Uthukela kz uMgungundlovu THCA ec Amathole 38 Solution: Fixing Retention Data to Fix the Program

COJ • Total (u)LTF = 25 618 • Total (u)LTF in 20 focus facilities = 16 519 (65%)

14000 11880 12000 10000 7736 8000 7087

6000 4692 3707 4000 2648 2612 2000 909 0 Sub-district C Sub-district D Sub-district E Sub-district G Jan 2018 Tier.net dispatches Feb 2018 Tier.Net dispatches

39 Solution: Rapidly Enrolling Patients in Differentiated Care Models

~70% of facilities have at least one modality 38% of ART clients are currently 38% have multiple options decanted in the 27 priority districts

Adherence Clubs 446,131 Patients

265 Sites

74 Sites 105 Sites External 303 Sites PuPs SFLA 480,269 287,701 Patients 120 Sites Patients

242 Sites 462 Sites

~1% have exited the decanting program

40 Above Site Portfolio Aligned to 90-90-90

• Focus on addressing remaining gaps with relevant and necessary activities • Several activities cancelled. Resources redirected to priority activities for COP18

41 Pharmacy

Stock Visibility Solution SyNCH RxSolution

Function • Weekly reporting of medicine • CCMDD ePrescribing and • Hosp. inventory management stock on hand parcel tracking and dispensing • Smart phone based • Web based • Desktop based

COP 18 • Upgrade to version 3: Receiving • Scale up coverage to 8 • Finalize platforming to web Priority and ordering functionality additional districts based version • Target sites for version 3: 2000 • Target sites for new Rx: 100

SyNCH: 189 RxSolution SVS: 3169 : 254

42 TLD: Updates on Progress toward Transition Progress toward TLD transition:

Jan-Mar-18 Apr-Jun-18 Jul-Sep-18 Oct-Dec-18 Jan-Mar-19 Apr-Jun-19 Jul – Sep 19 2015 ARV Tender

TLD Registrations Supplementary Tender

TLD: New patients 2019 ARV tender

TLD: Stable patients

• Phased transition to TLD starting in September 2018 • Estimated TLD transition completion by September 2019

43 Laboratory Instruments In Place – HRH Needed

FY18 – FY20 testing projections FY18 FY19 FY20 30% increase in VL VL 5,856,722 6,742,394 7,136,633 testing with Surge EID 612,872 643,515 675,690 TB 2,180,352 2,398,387 2,638,226

FY17 instrument testing capacities and unutilized capacities Instrument Capacity Unutilized Capacity VL 7,352,256 2,452,256 EID 1,013,760 430,072 TB 5,105,000 2,702,550

-National household HIV survey -Enhanced linkage to care evaluation -Treatment readiness among -Subnational modeling -OR HTS in presumptive TB pts ART eligible patients that opt out GP Adults -National & program data triangulation -Outcomes of NCD & HTS integration -Cost effectiveness of -Case-based surveillance -Community continuum of care implemented adherence strategy -HIV mortality validation -Rapid assessment of Surge Kickstart -TB care cascade CHW interventions for replication model -Joint TB/HIV national survey feasibility -Process & outcome evaluation of Surge CHW and FBO

Men -Demonstration of self screening and telephonic linkage among high-risk men

-VL and recency testing in ANC Surveillance -School-based sexuality & -Assessment of Option B+ -Impact of enhanced prevention evaluation implementation perinatal VL monitoring SRE -TB/HIV integration in ANC MCH -TB prevention in MCH

-DREAMS , HerStory AGYW outcome evaluations -School-based sexuality & prevention impact evaluation Adolescents, -Family-centered program (Let’s Talk) evaluation AGYW -Economic strengthening and HIV prevention RCT for vulnerable youth -Community gender norms and uptake of HIV services

-KP cascades from routine data -Social network uptake of self-testing among MSM -PSE & IBBS: FSW, MSM -Effectiveness of program adaptation for TGW -Transmission dynamics in KP and

bridging populations

Legend: Strategic Information Prevention & 1st 90 2nd 90 3rd 90 -Ongoing -New 45 -HOP Adult Men South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only Highest Q1 Performance Ever and Ramping up for High Season

VMMC Performance (#) Trend, July 2015 – December 2017 198,724 200000

180000 163,302 160000

140000 131,552 121,068 120000 102,489 33% 100000 Increase

80000 65,188 60000 55,764 47,403 48,879 49,763 40000

20000

0 July to Sep Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec 2015 2015 2016 2016 2016 2016 2017 2017 2017 2017

47 DMPPT Guides Where We Are Going

48 National HIV Burden: Men

1st 90*

2nd 90*

3rd 90** PLHIV = 2 542 120* 1st 90 = 88%* 2nd 90 = 63%* 3rd 90 = 80%**

49 Case Finding Key Interventions

Adult Men Living with HIV Key Interventions 1st 90*

• Targeted HTS Status Unknown

campaign, community 2nd 90* mobilization through

CBOs followed by rd Status 3 90** mobile testing Unknown* = • Index Testing 309 144 • Workplace Testing in male-dominated settings • Home-based testing

using Self Screening *Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694]

50 SIMS Confirms Missed Index Case Finding Opportunities

51 Index Testing Increasing and Needs to Scale

52 Self Screening to Scale

Self Screening Case Study - Preliminary Results HTS uptake by male partners from women attending ANC clinics Leveraging on: 700 • PITC to promote self 600 screening for index 73% 500 • ANC setting - pregnant women given self 400 screening kits to give to 55% 300 45% their partners

200 • Also applicable in other PITC programs, e.g. 100 6.2% VMMC settings

0 • Can be complemented Dsitributed Reached Used Confirmed Negative VMMC Positive Linked to by investment in CHW Care for promoting and • Uptake (self-screened) 55% / Actual tested (confirmed) 45% offering self screening, • HIV positivity rate 6.2% self screening distribution, and linkage • 70% who screened HIV+ did a confirmatory test and all linked to treatment to treatment and/or • Final results will be available in April/May VMMC

53 Linkage to Treatment – Key Interventions for Men

1st 90 Adult Men Living with HIV

Key Interventions • Community ART • Active referral through CHWs 2nd 90 • Male drivers/mobilisers • Extended hours • GP contracting Never in • Male lay workers care* = Never In Care 721 572 3rd 90

54 Targeted Extended Hours to Reach Men

Yield per CHC December 2017 – January 2018

Lillian Ngoyi 260 59 23% • December 2017 to date • 3 CHCs in Soweto Itireleng 271 48 38% • 16:00 – 20:00 • 1 HTS Counsellor per CHC • Total number tested: 573 Chiawelo 42 2 5% • Average yield 19%.

0 50 100 150 200 250 300 350 Total HTS HST_Pos Yield

Male age disaggregation for extended hours Female Age disaggregation - extended hours HTS HTS

>50yrs >50yrs 25-49yrs 25-49yrs 20-24yrs 20-24yrs 15-19 yrs 15-19 yrs <15 yrs <15yrs 0 50 100 150 200 250 0 50 100 150 200 250 <15 yrs 15-19 yrs 20-24yrs 25-49yrs >50yrs <15yrs 15-19 yrs 20-24yrs 25-49yrs >50yrs Total HTS 1 18 64 176 22 Total HTS 3 13 41 175 18 HTS Pos 0 1 9 47 5 Yield 6% 14% 27% 23% HTS Pos 0 0 3 37 5

Yield 7% 21% 28% Total HTS HTS Pos Yield

55 Community ART Initiation – 90% Same-Day Initiation

HST Demonstration Activity uMgungundlovu district - Outreach teams % TX_NEW # initiated July to December 2017 TX_NEW initiated in District ART in the 7000 (July - Dec) the community 6234 5908 community 6000 uMgungundlovu 980 5,824 17% UThukela 690 5,688 12% 5000

Zululand 309 6,843 5% 4000

% Community ART initiation by gender (July - 3000 Dec 2017) 100% 2000 90% 80% 70% 1000 586 641 560 60% 420 50% 40% 30% 0 20% Jul - Sep 17 Oct - Dec 17 10% Number tested Number tested positive Same day initiation 0% uMgungundlovu uThukela Zululand

male female

CommunityCommunity MappingMapping of of mobilisationmobilisation one one potentialpotential highhigh -yieldyield weekweek prior prior to to areasareas serviceservice

ReferralReferral for for ongoing ongoing ServiceService – – followfollow up up visits visits to to counsellingcounselling and and nearestnearest PHC PHC clinic clinic testingtesting and and ART ART initiationinitiation Linkage and Retention Key Interventions for Men

Adult Men Living with HIV Key Interventions • Enhance support and adherence groups • Linkage Officers • Extended clinic hours • Facility appointment systems • Community ART initiation LTFU* = 821 453 (36%)

57 Males Age 25+ Contribute 42% of Treatment Gap

Where do we need to focus? % Contribution to treatment gap City of Johannesburg City of eThekwini

250,000 250,000 M 25+ F <15 42% 200,000 200,000 F 15-24 150,000 150,000 F 25+ 100,000 M <15 100,000 50,000 M 15-24 50,000 - M 25+ - M <15 M 15-24 M 25+ M <15 M 15-24 M 25+

City of Tshwane City of Ekurhuleni

160,000 160,000

140,000 140,000 120,000 120,000 100,000 100,000 80,000 80,000 60,000 60,000 40,000 40,000 20,000 20,000 - - M <15 M 15-24 M 25+ M <15 M 15-24 M 25+ 58 Problem: Linkage without Retention is a Program Failure

59 Solution: Men-Friendly Services

• Facilities with TROA ≥1000 in the four DREAMS districts; TX_CURR for men ≥300; • ≥15% increase in men from Q1 FY17 to Q4 FY17, TX_RET ≥80% and PVLS ≥80%. • 50 facilities qualified of which 7 reported increases >50%. • Survey Monkey sent to partners to gather relevant program data (e.g. DSD support, core interventions coverage levels etc.)

Facility Partner TX_CURR TX_RET TX_PVLS gp Vosloorus Poly Clinic Aurum 1,612 81% 85% Consistent Across Geographic Types: gp Ramokonopi CHC Aurum 1,339 83% 81% • Urban, gp Phenduka Clinic Aurum 907 84% 81% • Peri-Urban, gp Stretford CHC Anova 1,995 95% 88% • Rural gp Orlando Prov Clinic Anova 1,981 85% 83% gp Dresser Clinic Aurum 1,280 82% 80% gp Goba Clinic Aurum 2,004 80% 84% gp Bophelong Clinic (Johannesburg A) Right To Care 630 82% 94% kz Charles James TB Hospital MatCH 1,384 84% 96% gp Zandspruit Clinic Anova 997 82% 91% gp Germiston City Clinic Aurum 1,962 87% 82% gp Michael Maponya Prov Clinic Anova 1,515 82% 88% kz Balgowan Clinic HST 451 81% 92% gp Nokuthela Ngwenya CHC Aurum 1,572 81% 86% gp Spartan Clinic Aurum 1,080 81% 87%

60 Children South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only 50% of OVC Targets Aimed at 10-17 Year Old Females FY19 OVC_SERV by Age

FY19FY19 OVC_SERV OVC_SERV Target Target by Age 626,600

ProportionFY19 FY19 OVC_SERV OVC_SERV Target Target by Age 2% 11% 36% 41% 7% 3%

0 100000 200000 300000 400000 500000 600000 <1 1-9 10-14 15-17 18-24 25+

FY19 OVC_SERV Targets by Age/Sex 5864 25+ 13702

18-24 26862 13888

15-17 157520 100995

10-14 123438 100995

-200000 -150000 -100000 -50000 0 50000 100000 150000

Note: 0-9 not collected by sex FY19 Target Females (inverted) FY19 Target Males 62 Improving Testing and Linkage for OVC

Strengthening linkage between community and Educating caregivers on clinical cascade the importance of knowing the 90 90 90 HIV status Strong supportive Referral for ART Ongoing support Motivate referral system initiation & for adherence & beneficiaries to support family- viral HIV risk access HIV Completion of centered suppression screening for HIV testing testing children and disclosure Continued support family members referrals at risk of HIV for family stability infection

Embedded in Case Management

63 Community-Based Violence Prevention & Linkage to Response

Post-Violence Care & Violence Prevention Response

Case Management

Specialized Training & Tools Psychosocial Support

64 PLHIV Burden: Children <15 Years

1st 90*

2nd 90*

CLHIV 317,942 3rd 90**

65 Case Finding Key Interventions for Children

Key Interventions CLHIV • Scale up Index testing st • Training and 1 90* mentoring of HCW Status Unknown and CHWs to increase case finding 2nd 90* • Implement revised school health policy Status Status UnknownUnknown* = 112 252 309 144 3rd 90**

* ?

66 Problem: Low Treatment Coverage in 4 Highest-Burden Districts

Where do we need to focus? % Contribution to treatment gap City of Johannesburg City of eThekwini F <15 9,000 12,000 2% 8,000 7,000 10,000 6,000 8,000 5,000 F <15 [CELLRAN [CELLRAN 4,000 [CELLRAN 6,000 [CELLRAN GE] GE] F 15-24 3,000 GE] GE] 4,000 F 25+ 2,000 1,000 2,000 M <15 - - M 15-24 F <15 M <15 F <15 M <15 M 25+ City of Tshwane City of Ekurhuleni

8,000 M <15 7,000 2% 7,000 6,000 6,000 5,000 5,000 Children <15 contribute 4% of total 4,000 4,000 treatment gap in 4 highest-burden 3,000 3,000 [CELLRAN [CELLRAN GE] GE] districts 2,000 [CELLRAN [CELLRAN 2,000 GE] GE] 1,000 1,000 - - F <15 M <15 F <15 M <15 67 Solutions for Children: Index Testing

Selection Criteria • Facilities with TROA ≥ 50 in the four DREAMS districts. • HTS Yield >4%; proxy linkage >100%; TX_RET ≥ 85%; TX_PVLS ≥ 80% • Survey Monkey sent to partners to gather relevant program data (e.g. DSD support, core interventions coverage levels etc.)

District Facility Partner TX_CURR TX_RET TX_PVLS Yield Linkage eThekwini Lancers Road HST 502 118% 92% 17% 101% eThekwini New Germany HST 244 117% 100% 11% 102% COJ Diepkloof Prov Anova 92 100% 100% 18% 240% Ekurhuleni Villa Liza Aurum 57 100% 88% 13% 500% COJ Jeppe WRHI 57 91% 83% 13% 460% eThekwini Fredville MatCH 78 90% 100% 9% 123% Ekurhuleni Ethafeni Aurum 52 90% 89% 23% 200% eThekwini Umlazi MatCH 84 88% 92% 7% 193% eThekwini Umlazi U21 MatCH 120 88% 85% 10% 200% COJ Lillian Ngoyi Anova 209 86% 84% 5% 386% eThekwini Hlengisizwe MatCH 356 85% 84% 6% 392%

68 Index Testing Scale-Up across Districts (Children)

Case Identification: Index Testing Highest-Burden Districts

585

485

385

285

185

-15 gp City of Tshwane Metro kz eThekwini Metro gp City of Johannesburg Metro gp Ekurhuleni Metro APR17 Results COP17 Targets Preliminary COP18 Targets

69 Problem: Poor Viral Suppression

5000 80%

4500 70% 4000 60% 3500

50% 3000

2500 40%

2000 30% 1500 20% 1000

10% 500

0 0% <1year 1-9years 10-14years 0 0.5 1 1.5 2 2.5 3 3.5 VLD VLS %Suppression

70 Retention and Clinical Management Key Interventions (Children)

Key Interventions CLHIV • Pediatric-friendly st services 1 90 • After school & weekend hours • Use of FBOs to 2nd 90 support On ART differentiated care On ART* = 168 666 3rd 90

71 Adolescent Girls and Young Women South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only

Aligned with She Conquers Programmatically…

73 …and Geographically

Johannesburg

Durban

Cape Town

74 Focus on 9-14 Year-Old Girls

Empowering AG Mobilize Communities Package of prevention for 9-14 (Targeting Traditional & Faith Leaders & year olds: Comprehensive Sexuality Education Healthy Choices I Educators to support, • preventing sexual violence (During contact time) (Co-curricular) protect & educate AG) and any form of coercive/ forced/non-consensual sex

Social Asset Building SASA! • preventing early sexual debut (Vhutshilo)/ Safe Spaces Social Protection • supporting healthy choices Community Leadership Training/ • helping parents and Community Action communities to support, Strengthen families Teams protect and educate. These prevention interventions will Orientation Families Let’s Talk Strengthening School- of Parents Matter! based structures leverage OVC platforms to target the most vulnerable, as well as faith-based organizations and Linkage to Health Services: traditional authorities.

SRHR incl Condoms HIV Testing PVC Linkage to C&T

75 Doubling PrEP Targets aligned with Government of South Africa

• NSP PrEP Target: 85,858 (2017-2022) (Assumes a 5% coverage among HIV-negative AGYW (15-24) in 22 priority sub-districts)

2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 Total Target Per 15-19 0 1,574 3,149 4,723 6,297 7,872 23,615 Age Band 20-24 698 2,536 5,072 7,609 10,145 12,681 38,741 Total 698 4,110 8,221 12,332 16,442 20,553 62,354

2017/18 2018/19 2019/20 2020/21 2021/22 Total COJ 379 759 1,518 2,429 2,505 7,590 eThekwini 699 1,397 2,795 4,472 4,612 13,974 Target Per Ekurhuleni 264 528 1,056 1,690 1,743 5,281 SNU Cape Town 125 250 501 801 826 2,503 uMgungundlovu 152 304 608 973 1,003 3,040 Total 1,619 3,238 6,478 10,365 10,689 32,388 76 National HIV Burden: AGYW

1st 90*

2nd 90*

3rd 90** PLHIV = 541 218* 1st 90 = 72%* 2nd 90 = 58%* 3rd 90 = 77%**

77 Case Finding Key Interventions for AGYW

Key Interventions AGYW Living with HIV

• Expansion of the 1st 90* standard package of Status Unknown AYFS 2nd 90* • Integration of school

rd health services, Status 3 90** including TB/HIV & Unknown* = STI screening 151 777 • Safe and accurate 1st 90: Status Unknown* = 28% self screening for HIV

78 Problem: Case Finding Gap (AGYW)

eThekwini

79 Solution: Adolescent and Youth-Friendly Services

Selection Criteria • Facilities with TROA ≥100 in the four DREAMS districts. • TX_RET ≥75%; PVLS ≥85%; Yield >9%; Linkage >85% • Survey Monkey sent to partners to gather relevant program data (e.g. DSD support, core interventions coverage levels, etc.) District Facility Partner TX_CURR TX_RET TX_PVLS Yield Linkage Ekurhuleni Villa Liza Aurum 101 91% 96% 13% 300% COJ South Rand WRHI 116 79% 87% 18% 187%

COJ Joubert Park WRHI 366 100% 94% 11% 171%

COJ Rabie Ridge RTC 255 76% 96% 24% 145%

COJ Alexandra East Bank Anova 267 99% 89% 14% 132%

COJ Vlakfontein Anova 104 79% 95% 17% 117%

COJ Stretford CHC Anova 345 93% 90% 27% 108%

eThekwini Charles James TB MatCH 111 89% 92% 39% 93%

uMgungundlovu Willowfountain HST 127 78% 94% 12% 90%

COJ Jeppe WRHI 327 96% 88% 14% 86%

80 Linkage and Retention to Treatment for AGYW

AGYW Living with HIV Key Interventions • Extended Hours • Youth Connectors • Adolescent & Youth-friendly Services Never in Care plus LTFU* = • I-ACT for ALHIV 162 136 • Youth Care Clubs (42%) • mHealth through B-wise mobisite and IEC through

AVIWE Program *Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694]

81 Problem: AGYW Contribute 16% of Total Treatment Gap in Highest-Burden Districts

Where do we need to focus? % Contribution to treatment gap City of Johannesburg City of eThekwini

60,000 60,000 F 15-24 50,000 50,000 16% 40,000 40,000 30,000 F <15 30,000 F 15-24 20,000 20,000 F 25+ 10,000 10,000 M <15 - - M 15-24 F 15-24 F 15-24 M 25+ City of Tshwane City of Ekurhuleni

40,000 45,000 40,000 35,000 35,000 30,000 30,000 25,000 25,000 20,000 20,000 15,000 15,000 10,000 10,000 5,000 5,000 - - F 15-24 F 15-24 82 Solution: Youth Care Clubs

• Youth Care Clubs (YCCs) aimed at improving ART adherence and viral load suppression in ALHIV • YCCs are facility-based supported by a Facility Manager and a clinician • YCC members meet monthly for the first 12 months; thereafter monthly or once every two months • 90% of members are virally suppressed at last recorded viral load • COP 18 scale-up in all PEPFAR supported facilities with >40 ALHIV

Age Group 12-15 16-19 20 - 25 Total % of ALHIV on ART in YCCs Gender male female male female male female Facility No. of clubs 80 Albert 2 0 0 3 5 5 25 38 18% Jeppestown 2 2 5 4 3 4 9 27 11% Joubert Park 1 1 0 1 2 3 19 26 11% Malvern 2 9 8 4 6 6 11 44 22% Rosettenville 1 1 0 1 6 1 19 28 20% Ward 21 6 13 15 17 19 7 13 84 14% Yeoville 1 0 1 1 5 4 11 22 5% Total 15 26 29 31 46 30 107 269 8% 83

Key Populations South Africa

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only FSW Clinical Cascade

35000 • Linkages to Care and 30000 Treatment

60% 25000 FSW reached Leakage:

20000 75%

FSW know their status 15000

10000 31% 80%

HIV+ FSW on Virally ART suppressed 5000

0 FSW Pop Est FSW LHIV FSW Know Status FSW on ART FSW VL Supressed

85 Strengthening the FSW Program

• Empower Peers • Communication through trained peers • Low linkage to and uptake Root Cause • Support groups (health & beauty of ART (and PrEP) groups to attract clients) • Peer navigation • Low VL suppression • Mobile lifestyle • Accessible Services • Lack of health literacy • Immediate T&T • Difficulty in accessing treatment • Mobile services, KP-friendly clinics • Stigma • Reach diverse networks • Misinformation • Widespread sensitization • Structural barriers • Link unreached KP • Social Network Strategy & EPOA Problem Solutions

86 MSM Clinical Cascade

• Uptake of HIV

140000 Testing Service

120000 Leakage:

100000 54% 54% 69% 76%

MSM reached MSM know their HIV+ MSM on ART Virally status 80000 suppressed

60000

40000

20000

0 MSM Pop Est MSM LHIV MSM Know Status MSM on ART MSM VL Supressed

UCSF, 2018 87 Strengthening the MSM Program Problem Low testing Root Cause Adherence HIV fatigue Solutions Low risk perception Empowerment Inaccessible HIV services •Mpowerment (gay- and sex-positive) Lack of demand creation/knowledge/awareness •Role models – through social and other media Stigma and discrimination (esp. rural and black MSM) Demand Creation Social Network Strategy and EPOA •Social media & online dating apps (e.g., Grindr, Badoo) •Provide a comprehensive package of health service (STI screening & treatment, prostate examinations, anal examinations)

Make Testing Easier •Self-testing kits with call-in link/support •Pop-up sites for testing in clubs •Mobile clinic and outreach testing through peers

Linkages Peer Navigation

Service Delivery •Immediate initiation plus POC creatinine tests •Mobile drug drop-off and follow-up tests •Male-friendly clinics and staff

88 Ambitious Targets for Key Populations

% Coverage % % of Neg in % MAT of in HTS_TST TXT_NEW KP Group KP_PREV Coverage PrEP_New Catchment MAT HIV Catchment (30 %) (90%) Total Pop Area Negative Area

FSW 53,955 95% 48% 20,133 3,788 4,290 17%

MSM 49,734 29% 17% 32,851 2,689 6,736 12%

TGW 4,197 50% 6% 7,555 1,360 857 10%

PWID 5,554 93% 8% 5,141 648 442 16% 442 16%

Inmates 71,122 55%

184,562 65,680 8,485 12,325 TOTAL 442 18% 32% 70% 60%

89 What’s New in COP18?

COP 2018 Regional Planning Meeting March 1, 2018

Internal Use Only APR17 Results Were Not on Track…

FY18 Q1 Achievement by DSP, 27 focus districts

FY18 Q1 Proxy Linkage, FY18 Q1 Partner HTS_TST HTS_TST_POS TX_NEW Outlay facility Outlay

92 The New Direction to Get on Track

93 Implementing and Intensifying Evidence-Driven Solutions

Case Finding

• Scale index testing • Self screening • Community health workers • Supplemental staff

Linkage

• Direct linkage measure action • Community ART • Community health workers • Peer led patient navigators by population • Supplemental staff • National screening, testing, and treatment campaign • Evidence-based communication campaign • GP contracting

Retention

• Treatment literacy communication • Adherence clubs by population • Engage faith based and traditional leaders • CCMDD – increase external pick up points • Community health workers • Targeted placement of Linkage and Retention Officers

More Than Double DSD Staff in Facilities and Communities

HR H_ C UR R T im e T r e n d : C O P1 5 t h ro u g h P ro je ct e d C O P 18

- 5 ,0 0 0 1 0, 0 0 0 1 5, 0 0 0 2 0, 0 0 0 2 5, 0 0 0 3 0, 0 0 0

C OP 1 5 H R H _C U R R

Actual

C OP 1 6 H R H _C U R R

C OP 1 7 H R H _C U RR pr o je c te d ( HR ID C OP 1 7 Q 1 + K i ck S t ar t ) Projected 8,361 COP17

C OTotalP 1 8 H R H _C U R R pr o je c te d 8 ,4 7 6 1, 9 92 4, 7 8 0 4 ,7 8 0 6 ,1 90 1 ,9 2 6 ( TCOP18i e re d mo d el + K i ck S ta r t ) Projected C l in i c al C l in ic al S u p po rt M an ag e me n t L ay K ic k S t a r t C H Ws K ic k S t a r t O T Ls

95 Community Health Workers

Community Health Workers & Outreach Team Leaders Current versus COP18 Proposal

- 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000

In place COP17 Q1 (HRID) 1,010 4 CHWs proposed here are in addition to the 51,364 CHWs supported by the Department This year COP17 2,690 87 of Health.

Original Proposal COP18 proposal 1 4,190 1,726

Revised COP18 current proposal 6,190 1,926 Proposal

CHWs OTLs

96 Creating Space to Meet the Needs of All Populations

Increase space for Direct Service Delivery to reduce crowding and meet the needs of men, adolescents, and pediatric populations

Kwamakhuta Clinic

97 Expansion of ARV Procurement

COP 18 Commodity Budget by Major Category

VMMC, ARV Procurement $10,729,657 Labs, $504,209 CCMDD , $10,000,000

PrEP , $1,530,600 $42.98 $37.76 mil mil

ARVs, $42,983,257 COP 17 Kick Start COP 18

Total commodity investments: $ 65.7m

98 Integrating with Faith-Based Organizations and Traditional Structures

• Engage FBO, CBO, Community Structures to expand reach into communities • Provide HIV information • Create demand for HIV testing • Promote community and facility HIV services • Link PLHIV with adherence clubs and support groups • Address social and gender norms, stigma that are barriers to HIV service uptake • FBO/CBO involvement in CHW expansion

99 Ensuring Data Quality and Use to Improve the Program

Facility Coverage of TIER.Net, UID & Weekly Review Implementation as of January 2018 Facility WebDHIS Coverage 120% 100%

98% 100% COP 18 80% >80% 80% 60% COP 18 60% 52% 95% 50% 42% 40% 40%

20% 20% 20% 0% 0% Facilities using with UID (% of TROA) Facilities reviewing Facilities reporting Direct webDHIS Tier.net weekly data into WebDHIS reporting

100 Rapid Expansion of Private Sector Engagement

• Central Medicine Procurement Unit • NHLS supply and collect • Reduce DOH audit burden consumables and samples for GPs • Aligned with National on existing routes PMPU/Control Tower supply chain • GP Model budget code: District design • GP or GP network registered as • Demand planning and forecasting demander with NHLS • DOH Designated Program • List of approved lab tests – as per Manager: PFMA Authorizations etc STGs • Registered pharmacy premises for warehousing function Supply NHLS Chain

GP + • ePrescribing HMIS Pharmacy •Network, Individual service providers • Reporting into TIER.Net: GPs in Networks catchment area “affiliated” to •GPs with dispensing licenses and reporting clinics community pharmacies • HTS registers? •Entry into point of care: HTS •Referral path : District hospitals •GPs registered as CCMDD PUPs

101 Rapid Expansion of USG Provincial Engagement for Oversight

• Political Engagement • Chief of Mission (COM), Deputy Chief of Mission (DCM), and Consuls General (CG) engage in health diplomacy at the Health provincial level Political Systems Engagement Strengthening • PEPFAR Coordinator regular engagement Partners with senior provincial officials to facilitate strategic engagement • Technical Engagement through Agency Provincial Agency Points Points of Contact Support of Contact • At least monthly engagement with provinces Partners • Accelerate the performance feedback loop • Close management of the Provincial Support Partner (PSP).

102 Innovative System to Engage CBOs through Community Grants

Section

103 Partner Shift: Foundation for Professional Development

FY16 FY17 % Target Achieved % Target Achieved Districts Linkage TX_NEW TX_CURR Linkage TX_NEW TX_CURR TX_NET_NEW ec Amathole District Municipality 31% 258% 11% 41% 81% 0% -296.00 ec Buffalo City Metropolitan Municipality 63% 62% 33% 68% 327% 1640% 57444.00 gp City of Tshwane Metropolitan Municipality 71% 41% 56% 80% 32% 72% 17267.00 lp Capricorn District Municipality 62% 66% 16% 97% 69% 83% 14551.00 mp Nkangala District Municipality 75% 149% 165% 86% 37% 73% 24911.00

Partner Management Response: Immediate Remediation • Reallocating FY2018 targets (138,801 TX_CURR Targets) and budget ($5,793,033) from Foundation for Professional Development to Right to Care in Tshwane Medium-Term Remediation • New procurement: Accelerating Program Achievements to Control the Epidemic (APACE) in South Africa • Expected award in June to transition sites in Q4 and begin reporting in Q1. • USAID has not fully obligated COP17 resources into current mechanisms in case an underperforming partner needs to be replaced immediately upon award

104 Partner Improvement: Q1 Improvement on Q3 and Q4!

Partner Management Response: • Targets not achieved by SAPR 17

• CDC-Aurum program performance review and deep dive Aurum Comprehensive VMMC Performance • Initiated weekly data-driven monitoring calls and monthly (IM18484) remediation reviews 25,000 • Increased number of CDC site visits for monitoring and rapid problem resolution 20,000 • CDC formed a new award to separate VMMC from DSPs 15,000 to manage more closely • Supported Aurum to appoint a new Aurum VMMC Director 10,000 and Program Manager 5,000 • Supported Aurum to appoint a new sub-partner in certain districts - FY17Q1 FY17Q2 FY17Q3 FY17Q4 FY18Q1 • Established a ‘war room’ approach for weekly Aurum Oct-Dec 2016Jan-Mar 2017 Apr-Jun 2017 Jul-Sep 2017 Oct - Dec VMMC meetings 2017

Aurum achieved 89% of Q1 target

105 Partner Management Approach

Manage for Impact

Operation 10-10 Site Intervention: Program Review – Fidelity, Scale, Quality • Heard about Namibia on February 25th Administrative Oversight – investment, expenditure, results • On March 5th will implement in 10 highest- Both volume facilities in 10 highest-burden

districts 106 40 SOPs – Guide Partner Workplans at Every Site!

1. Fidelity 2. Standardization 3. Transparency 4. Partner Monitoring

107 Required COP Elements Finalized at RPM Complete

Tool Completed Datapack Yes FAST Yes Table 6 Yes TLD Forecast Tool and Transition Plan Yes Laboratory Instrument Mapping and Optimization Tool Yes SRE Inventory Yes

108 Engagement with All Stakeholders Continues Moving Forward:

Index Testing VMMC CHWs CSO Partnership “Send me!” – We are Ready!

I wanna be there when the people start to turn it around When they triumph over poverty I wanna be there when the people win the battle against AIDS I wanna lend a hand I wanna be there for the alcoholic I wanna be there for the drug addict I wanna be there for the victims of violence and abuse I wanna lend a hand Send me – Hugh Masekela

110