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PROJECT SUMMARY Project Name:

Ending AIDS in West Africa Project (#EAWA); CA No. AID-624-A-17-00004 Life of Project (start and end dates): September 29, 2017 – September 28, 2022 Total Estimated USAID Amount: $16,500,000 Goal: Achieve HIV epidemic control in West Africa by accelerating progress across the region towards Ending AIDS through prevention, care and treatment, and accelerating of achievement of UNAIDS 90-90-90 targets with a focus on Key Populations and PLHIV Project Objectives: • Improve service delivery at community and health facility level • Strengthen the viral load laboratory system • Strengthen the monitoring and evaluation system

Prime Awardee: FHI 360 Project sub-awardees for FY20:

– 25 health facilities (20 DSD and 5 TA – SDI sites) in Togo – 17 health facilities (DSD sites) in Burkina Faso

Submission of Report Date: July 30, 2020

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TABLE OF CONTENTS

TABLE OF CONTENTS...... iii LIST OF ACRONYMS...... iv Section 1. Summary ...... 6 Section 2. Description of main results achieved ...... 10 Description of results achieved under the service delivery component ...... 10 HIV Prevention achievements ...... 10 HIV testing, linkage and ART initiation...... 14 Retention on ART and viral load suppression ...... 29 Full cascade of prevention, care and treatment ...... 32 Trend of key performance indicators from Q1 to Q3 ...... 34 Impact of the COVID-19 in achievements of project targets ...... 35 Description of results achieved under the KPIF project ...... 36 Implementation of the Environmental Monitoring and Mitigation Plan (EMMP) ...... 39 Protecting Life in Global Health Assistance (PLGHA) ...... 39 Section 3. Discussion of challenges to implementation ...... 40 Monitoring of key assumptions...... 41 Section 4. Activities planned for next quarter ...... 42 Section 5. Financial brief ...... 43 1-Obligated amount ...... 43 2- Expenditures for Q3 FY20 and Cumulative Expenditures ...... 43 3- Subgrantees Disbursements (Q3 FY2020) and cumulative ...... 45 4- Next Quarter Projections (Q4 FY2020) ...... 46 5- Next Quarter Subgrantees Planned Disbursement (Q4 FY2020) ...... 48

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LIST OF ACRONYMS

ART Antiretroviral Therapy

CCM Country Coordinating Mechanism

COPCT Continuum of Prevention, Care and Treatment

CSO Civil Society Organization

DIC Drop-in Center

EPOA Enhanced Peer Outreach Approach

FHI 360 Family Health International

FSW Female Sex Worker

GBV Gender-Based Violence

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

HIP High Impact Practice

HTC HIV Testing and Counseling

IPs Implementing Partners

KP Key Populations

KPIF Key Populations Investment Fund

M&E Monitoring and Evaluation

MoH Ministry of Health

MSM Men Who Have Sex with Men

NAC National Commission for the Fight against HIV/AIDS

NGO Non-Governmental Organization

PE Peer Educator

PEPFAR The US President Emergency Plan for AIDS Relief

PLHIV People Living with HIV

PMP Performance Monitoring Plan

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PSSLS Programme Sectoriel Santé de Lutte contre le Sida et les IST

RHO Regional Health Office

RNR Risk Network Referral

ROP Regional Operational Plan

SBCC Strategic Behavior Change Communication

SOP Standard Operating Procedures

STI Sexually Transmitted Infections

TA Technical Assistance

UNAIDS Joint United Nations Program on HIV/AIDS

USAID United States Agency for International Development

USG United States Government

VLS Viral Load Suppression

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Section 1. Summary The Ending Aids in West Africa (#EAWA) project is a five-year cooperative agreement between the United States Agency for International Development West Africa Mission (USAID/WA) and Family Health International (FHI 360). #EAWA was initiated with the goal of accelerating progress across the region towards Ending AIDS in West Africa through prevention, care and treatment, focusing on Key Populations to accelerate the achievement of UNAIDS 90-90-90 targets. From the second year of implementation of the #EAWA project (FY19), the US President Emergency Plan for AIDS Relief (PEPFAR), the main source of funding of #EAWA, undertook a major shift in programming in some West African countries. Because Togo and Burkina Faso have demonstrated the greatest progress nationally on the HIV clinical cascade, the PEPFAR West Africa Regional Operational Plan (ROP) 19, allocated additional funding to accelerate progress towards achieving the UNAIDS 95-95-95 goals. This funding was awarded through the Game Changer Fund to support the intensification of case finding strategies, linkage to care and retention, and viral load suppression (VLS), thus significantly improving their HIV/AIDS clinical cascades in two years (FY20 and FY21). With the Game changer funds, the project will go beyond KP programing and will target also general population. Therefore, the goal of #EAWA has evolved to: “achieve HIV epidemic control in West Africa by accelerating progress across the region towards Ending AIDS through prevention, care and treatment, and accelerating the achievement of UNAIDS 95-95-95 targets with a focus on Key Populations and PLHIV”. In this context, #EAWA oversees three components of the Game Changer strategy: (i) the service delivery component, (ii) the viral load laboratory system strengthening component, and (iii) the monitoring and evaluation component. With the service delivery component of the Game Changer funds, PEPFAR aims to reach nationally the first and second 90 in FY20 in Burkina Faso and Togo, and achieve the third 90 in FY21 through direct service delivery, with a targeted focus on the highest burden sites for PLHIV and KP (Centre, Hauts Bassins, and Centre Ouest Regions in Burkina Faso; Lomé Commune, Maritime, and Plateaux Regions in Togo), and with technical assistance to other sites. The Key Population (KP) program is also supported by the two-year (FY20/FY21) Key Populations Investment Fund (KPIF) via the Meeting Targets and Maintaining Epidemic Control (EpiC) project that is also led by FHI 360. This progress report depicts achievements and activities conducted during the third quarter of year 3 - period of April 1 to June 30, 2020 as part of the implementation of the #EAWA project. This report highlights also the achievements of the third quarter of implementation of the Game Changer Funds.

Summary of achievements on Key indicators • HIV prevention, testing, ART initiation, retention, and viral load suppression cascade During the third quarter of this fiscal year, April 1 to June 30, 2020, a total of 5,237 individual key populations (2,672 MSM and 2,565 FSW) were reached with prevention interventions in both Togo (3,441) and Burkina Faso (1,796). 27,150 individuals (including 3,994 KPs) were tested for HIV and received their test results. Among those who received an HIV test, 4,252 individuals (including 464 KPs) were newly diagnosed HIV positive (15.7% case finding). Among individuals newly diagnosed HIV

6 positive, 4,055 (including 425 KPS) were newly enrolled on ART in the course of the quarter (95.4% ART linkage rate). The ART linkage rate in the two implementing countries is 95.4% (96.8% in Togo and 91.7% in Burkina Faso). The ART linkage rate is higher among female than male (97.7% vs 95.3% in Togo and 92.9% vs 89.2% in Burkina Faso). The table 1 below provides an overview of the cascade from the HIV testing to the viral load suppression.

Table 1: Overview of the cascade of COPCT in Q3/FY20 HTS_TST HTS_TST_POS TX_NEW TX_CURR VL VL suppressed (yield) (%ART linkage) documented (TX_PVLS) Togo 20,315 3,082 (15.2%) 2,982 (96.8%) 29,505 8,354 6,847 (82.0%) Male 8,837 1,165 (13.2%) 1,110 (95.3%) 8,778 2,268 1,821 (80.3%) Female 11,478 1,917 (16.7%) 1,872 (97.7%) 20,727 6,086 5,026 (82.6%) Burkina Faso 6,835 1,170 (17.1%) 1,073 (95,7%) 21,662 1,383 1,094 (79.1%) Male 2,183 369 (16.9%) 329 (89.2%) 5,822 371 288 (77.6%) Female 4,652 801 (17.2%) 744 (92.9%) 15,840 1,012 806 (79.6%) Overall #EAWA 27,150 4,252 (15.7%) 4,055 (95.4%) 51,167 9,737 7,941 (81.6%) Male 11,020 1,534 (13.9%) 1,439 (93.8%) 14,600 2,639 2,109 (79.9%) Female 16,130 2,718 (16.9%) 2,616 (96.2%) 36,567 7,098 5,832 (82.2%)

As of June 30, 2020, the project recorded a TX_CURR of 51,167 ART patients receiving treatment including 29,505 ART patients in Togo and 21,662 ART patients in Burkina Faso. Compared to the annual target, the project has to date achieved 95% of the annual target of TX_CURR in Burkina Faso and 79% of the annual target in Togo. The viral load data was extracted from the databases of the national electronic laboratory information system in both countries with a completeness of 100% in Togo and 35% (6 sites out of 17) in Burkina Faso. At the end of June 2020, viral load results were documented for 9,737 ART patients (8,354 patients in Togo and 1,383 patients in Burkina Faso). The percentage of ART patients with a suppressed viral load (VL) result (<1000 copies/ml) compared to those who accessed the VL test at the end of quarter 3 is 82.0% in Togo and 79.1% in Burkina Faso.

• Achievement on core indicators by country Based on a quarterly benchmark of 75% achievement for key indicators and the composite index targets assigned by USAID at the end of quarter 3, the project has reached the set target for KP_PREV in Togo (47%) and in Burkina Faso (45%). The performance for KP_PREV in both countries includes the contribution of the Key populations investment fund (KPIF) project, the implementation of which started in February 2020 in Togo and in April 2020 in Burkina Faso. Except the KP_PREV, the quarter 3 achievement of most key indicators has decreased slightly during this third quarter. The program was expecting strong growth in Q3 due to the heavy technical assistance and support provided to all sites after the large FY19 to FY20 scale-up. However, with the global COVID-19 pandemic, the heavy technical assistance and support provided in quarter 3 were hampered by the COVID-19 mitigation, consequently the project’s results experienced only a slight decrease, which demonstrates the resilience of the project to maintain results.

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The Figures 1.a & 1.b provide an overview of the project performance in Q1, Q2 and Q3 in Togo and Burkina Faso respectively. Figure 1.a: Number and Percent of FY20 annual targets achieved in Q1, Q2 and Q3 (Togo)

Figure 1.b: Number and Percent of FY20 annual targets achieved in Q1, Q2 and Q3 (Burkina Faso)

Table 2: Cumulative performance for FY20 up to June 2020 HTS_TST HTS_TST_POS TX_NEW TX_CURR # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative Togo 112,073 57,330 51% 13,571 9,306 69% 15,265 8,970 59% 37,490 29,505 79% Burkina Faso 44,128 17,828 40% 4,687 3,400 73% 5,279 3,350 63% 22,799 21,662 95% Overall #EAWA 156,201 75,158 48% 18,258 12,706 70% 20,544 12,320 60% 60,289 51,167 85%

8 Compared to the composite index targets assigned by USAID at the end of quarter 3, the project has reached the set target for TX_CURR in Burkina Faso (95%).

• Key strategies and innovations Detailed information on the strategies that were implemented to achieve Q3 results are provided in section 2. Strategies for reach: - The involvement of additional Peer educators (PE) from FSW and MSM population groups in Togo as part of the implementation of the KPIF project; - The assignment of granular specific targets to Peer educators (PE) in their geographic area; - The reinforcement of individual outreach activities (one to one sessions) for key populations; - The organization of EPOA (Enhanced Peer Outreach Approach) campaigns in both countries; - The implementation of online prevention and referrals (mainly for MSMs) in Togo. Strategies for HIV testing, linkage and ART initiation - The partnership with surrounding private clinics for the referral of patients suspected of being HIV positive; - The implementation of diversified case finding strategies such as index testing including partner notification services, risk network referral (RNR), and targeted PITC; - The intensification of targeted community testing to those most at risk; - The provision of transportation fees for ART initiation; - The involvement of case managers and peer navigators as HIV testing counselors and first contact in the linkage to ART for HIV positive; - Tailored supervision and coaching to health facilities staff involved in the project; - The implementation of test and start strategy. Strategies for ART retention, adherence support and viral load improvement - Differentiated follow-up and home visits by health providers and case managers; - Individual and/or group counseling on treatment adherence by health providers; - Appointment reminders through SMS and phone calls or home visits by case managers; - The use of the e-tracker to track those lost to follow-up ART patients and re-engage them on treatment; - The implementation and scale-up of community ARV refills; - The transportation of viral load samples to the laboratory.

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Section 2. Description of main results achieved Description of results achieved under the service delivery component

HIV Prevention achievements • KP_PREV During this third quarter of the fiscal year 2020, a total of 3,441 unique Key populations (2,184 MSMs and 1,257 FSWs) were newly reached with prevention interventions in Togo. This achievement includes results performed under the KPIF project. 187% of the quarterly target and 107% of the annual target (cumulative FY20 year to date) of the KP_PREV was achieved in Togo. Among MSMs reached during this quarter, 7.6% (165/2,184) have identified themselves as sex workers. By HIV testing services disaggregates as depicted in Figure 2.a, 82% of the KPs reached (2,817/3,441) were newly referred and/or tested, 5.2% (181/3,441) declined HIV testing and/or referral and 0.5% (n= 16) self-disclosure as known HIV positive. Peer educators stated that some of the KPs who refused to test already knew their HIV status and some of them were HIV positive.

Figure 2.a: KP_PREV disaggregates by testing services in Q3/FY20 in Togo

Accepted refered Not eligible Declined Known Positive 4000 16 3500 181 3000 3441 427 2500 82% 2817 2000

1500

1000

500

Number of NumberKPs 0 Reached KPs Test Eligibility

The Figure 2.b shows that the percentage of KPs who accepted referral and/or HIV testing is the same among FSWs and among MSMs (82%).

10 Figure 2.b: KP_PREV disaggregates by testing services and KP type in Q3/FY20 in Togo

In Burkina Faso, a total of 1,796 unique Key populations were newly reached with prevention interventions (488 MSMs and 1,308 FSWs). This represents 179% of the quarterly target and a cumulative annual achievement of 98% FY20 year to date. The quarterly achievement of KP_PREV includes results performed under the KPIF project, the implementation of which started in April 2020 in Burkina Faso. 1.4% of the MSMs reached in Burkina Faso during this quarter (7/488) declared themselves to be sex workers. Among KPs, 89% reached (1,606/1,796) were newly referred and/or tested, and 52 declined HIV testing and/or referral. (Figure 3.a). Figure 3.a: KP_PREV disaggregates by testing services in Q3/FY20 in Burkina Faso

Accepted refered Not eligible Declined Known Positive 2000 52 1 137 1500 1796 89% 1606 1000

500

0 Reached KP Test Eligibility

11 The percentage of KPs who accepted referral and/or HIV testing is higher among FSWs (90%) than among MSMs (87%) as illustrated in the Figure 3.b.

Figure 3.b: KP_PREV disaggregates by testing services and KP type in Q3/FY20 in Burkina Faso

• Online prevention and referrals In the context of the COVID-19, the #EAWA team in Togo has intensified the use social media for online HIV prevention and referrals for HIV services uptake. This activity is conducted by EVT towards men who have sex with other men (MSM). Three MSM, knowledgeable in social media were recruited among skilled peer educators to conduct Online prevention and referrals. They have been already trained in the use of social media for HIV prevention, HIV and STI testing, gender-based violence, stigma and discrimination messaging, and on social media data collection and reporting. They are equipped with laptops and smartphones that they use for internet connection. From April to June 2020, the social media campaign recorded 151 new MSMs and 219 MSMs contacts reached online in Togo. 38% of the MSMs contacts were reached through Facebook and 24% via Gay Romeo (Figure 4).

12 Figure 4: Proportion of MSMs reached by type of social media in FY 20 Q3 in Togo

7% 5% 13% 7%

6%

38% 24%

Badoo Drague.net Facebook Gay Romeo GindR Tango WhatsApp

Among the 219 contacts reached during this quarter, 176 were referred to a service such as HIV testing and STI screening. Some of 176 MSMs were referred for both services. Of those referred to a service, 80% (n= 140) reported to have accessed the service. 146 MSMs were referred for HIV testing and 88% (n= 128) received an HIV test. 118 MSMs were referred for STI screening and 76% (n= 90) reported accessing the referred service.

• Gender based violence prevention and clinical care In quarter three, 744 people were sensitized on gender-based violence (GBV) norms and prevention including 457 individuals in Togo and 287 individuals in Burkina Faso. Sensitizations on GBV are conducted by Peer educators (PE) during SBCC outreach activities. 41 people received post gender-based violence clinical care including 2 sexual violence. Post-exposure prophylaxis was provided to those who were exposed to sexual violence.

• Key strategies for reach Peer education strategy is based on individual and/or small group discussions in the drop-in centers and on assigned hotspots. During this quarter, additional Peer educators (PE) from KP groups (MSM and FSW) recruited in Togo under the KPIF project have been involved in outreach activities. Specific targets were assigned to each PE within his assigned geographic area. These PE are supervised by peer supervisors who are mostly former skilled and experienced PE.

13 With the support of the KPIF project, EPOA (Enhanced Peer Outreach Approach) campaigns have been organized during this quarter in Togo. Due to the COVID-19 outbreak in March 2020 and the limitations for group activities, KPs outreach activities were focused on individualized counseling sessions in the two countries of implementation. In Togo, the project reinforced the implementation of online prevention and referrals. This activity is conducted only for MSMs and is organized by experienced former MSMs Peer educators.

HIV testing, linkage and ART initiation • HIV testing to ART initiation cascade by country Togo During this quarter, 20,315 individuals (11,478 female and 8,837 male)1 were tested for HIV and received their tests results (HTS_TST) in Togo achieving 73% of the quarterly set target and a cumulative annual achievement of 51% year to date. The HTS_TST_POS among all target populations in Togo during quarter 3 were 3,082 (1,917 female and 1,165 male). This represents 15% case finding and 91% achievement of the quarterly target and 69% of the cumulative annual achievement year to date. Among those diagnosed HIV positive, 96.8% (2,982/3,082) were newly enrolled on ART during the reporting period (Figure 4.a). 78% of the quarterly target and 59% of the annual target2 of TX_NEW were achieved at the end this quarter. The volume of HTS_TST_POS and TX_NEW recorded in Togo decreased a little during this quarter compared to the previous quarter most likely due to reduced outreach and testing at the community level, and reduced client demand for HIV services due to the COVID-19 pandemic. The project’s implementation during this quarter was affected by the outbreak of the COVID-19 disease in the two countries that led to several malfunctions in the health systems which negatively impacted the results of the project. Thus, the triage instituted at the entrance to health facilities, the fear of patients to come to health facilities, etc., reduced access to HIV testing and consequently impacted on the case finding and the linkage to ART. However, the project made some adaptations to be resilient during the context of the COVID-19 (Figure 5.a) by introducing new activities and/or reinforcing existing activities such as online prevention and referrals, community testing, the organization of weekly sub-awardees coaching and performance review via virtual platforms (Microsoft Teams and Zoom).

1 These data include the KP (MSM and FSW). 2 The target for TX_NEW is greater than the target of HTS_TST_POS. despite the high linkage to ART rate, the performance of TX_NEW is lower than the performance recorded for the HTS_TST_POS.

14 Figure 5.a: Trend of weekly achievements by end of June 2020 in Togo

The Figure 5.b illustrates the cascade of HIV testing to ART initiation at the end of quarter 3 in Togo. Figure 5.b: HIV testing to ART initiation cascade in Togo – FY20/Q3

15 Burkina Faso In quarter 3 of the fiscal year 2020, a total of 6,835 individuals (4,652 female and 2,183 male) were offered HTS_TST in Burkina Faso and 17.1% (1,170/6,835) were newly diagnosed HIV positive. Among those diagnosed HIV positive, 91.7% (1,073/1,170) were newly enrolled on ART (Figure 5.b). By the end of quarter 3, the project achieved 62% of the quarterly target for the HTS_TST; 99% for the HTS_TST_POS; and 81% for TX_NEW. As of June 30, 2020, the annual target in Burkina Faso was achieved at 41% for the HTS_TST, 73% for the HTS_TST_POS and 64% for the TX_NEW. The volume of HTS_TST_POS and TX_NEW recorded in Burkina Faso has increased during this quarter compared to the previous quarter. The adaptative measures implemented in Burkina contributed to the resiliency of the project during the context of the COVID-19. These innovative strategies and initiatives include, among others, the reinforcement of the community testing, and the organization of weekly sub-awardees coaching and performance review via virtual platforms (Microsoft Teams and Zoom). In addition, a catch-up plan was developed and implemented in May and June 2020 with strong achievements (Figure 5.c). Figure 5.c: Trend of weekly achievements by end of June 2020 in Burkina Faso

The implementation of this plan made it possible to achieve the results achieved at the end of this quarter (Figure 5.d).

16 Figure 5.d: HIV testing to ART initiation cascade in Burkina Faso – FY20/Q3

• KPs cascade by country Togo During this quarter, 3,441 individuals among KPs (1,257 FSWs and 2,184 MSMs) were newly reached with prevention interventions in Togo. Among the KPs reached, 82% (2,817/3,441) were eligible for HIV testing. 2,599 KPs (927 FSWs and 1,672 MSMs) were tested for HIV and 12.3% (321/2,599) were newly diagnosed HIV positive. Among KPs diagnosed HIV positive, 95% (305/321) were enrolled on ART in the course of the quarter. As shown on Figure 6.a, the case finding rate is higher among MSMs (13%) than among FSWs (11%). The linkage to ART rate is high for both FSWs (94%) and MSMs (95%).

17 Figure 6.a: KP cascade in Togo – FY20/Q3 2200

82% 1700 93% 1672 82% 1200 90% 2184 1790 11% 700 1257 1027 927 94% 13% 95% 200 103 97 218 208

-300

HTS_TST HTS_TST

TX_NEW TX_NEW

KP_PREV KP_PREV

HTSeligible HTSeligible

HTS_TST_POS HTS_TST_POS FSW MSM

Burkina Faso From April to June 2020, 1,796 individuals among KPs (1,308 FSWs and 488 MSMs) were newly reached with prevention interventions in Burkina Faso. Among the KPs reached during this quarter in Burkina Faso, 89% (1,600/1,796) were eligible for HIV testing. Among KPs reached during this quarter 1,395 (1,093 FSWs and 302 MSMs) were tested for HIV and 10.2% (143/1,395) were newly diagnosed HIV positive. Among KPs diagnosed HIV positive, 84% (120/143) were newly enrolled on ART during the quarter. The linkage to ART rate is less than 90% for both MSMs (86%) and FSWs (84%). About 26% of the KPs newly diagnosed HIV positive in Burkina Faso (mostly within FSWs) were not linked to ART during the quarter. This is due to a noted pattern of instability among the KPs. Some of those who were not enrolled on ART explained also that they were not yet psychologically ready to start long term anti-retroviral therapy. Tailored technical assistance on the motivational interviewing (MI) and on the individualized care and support for the newly diagnosed HIV positive will be planned for health care workers in project supported sites in Burkina Faso during next quarter. The training in MI will improve care providers’ client communication and lifestyle counseling behaviors. Using MI will improve and enrich their practice work with patients who are resistant, or less ready to change and start taking ART.

The Figure 6.b provides an overview of the cascade for FSW and MSM during quarter 3.

18 Figure 6.b: KP cascade in Burkina Faso – FY20/Q3

1400 90% 1200

1000 93% 800 1308 600 1178 1093 11% 86% 400 72% 84% 200 488 422 302 7% 86% 122 102 21 18

0

HTS_TST HTS_TST

TX_NEW TX_NEW

KP_PREV KP_PREV

HTSeligible HTSeligible

HTS_TST_POS HTS_TST_POS FSW MSM

• HTS by modality and by country This section highlights the contribution of HTS modalities to the overall HTS and case finding achievements during the quarter.

Togo In Togo, 20,315 individuals received HIV testing service and received their test results during this quarter. The HIV testing yielded 3,082 HIV positive newly diagnosed for a case finding of 15%. As presented in graph 7.a, 32% (n= 6,496) of the HTS achievements during this quarter were performed through VCT (in the facility and in the community); 19.3% through Mobile modality (n= 3,930); 11.3% through Emergency modality (n= 2,299); and 10.2% (n= 2,073) through index testing. The overall HTS_TST_POS reported during this quarter is 3,082 among whom about 23% (n= 706) through VCT modality; 22% (n= 688) through index testing; 18% through Mobile modality (n= 542); and 9% through Emergency yard (n= 282). With 10% of contribution to the HTS_TST and 22% to the case finding, the index testing modality recorded the highest yield (33%) as presented in graph 7.b.

19 Figure 7.a: Contribution of HTS modalities to testing and case finding in Togo – FY20/Q3

Figure 7.b: HIV testing and case finding by HTS modality in Togo – FY20/Q3

Burkina Faso The graphs 8.a and 8.b depict the distribution of HIV testing and case finding by HTS modalities in Burkina Faso. In Burkina Faso, most of the HTS_TST (83.5%) and HTS_TST_POS (81%) results were achieved through VCT modality during this quarter.

20 The Index testing modality contributed to 5.7% of the HIV testing and to 10.9% of the case finding with a yield of 32%.

Figure 8.a: Contribution of HTS modalities to testing and case finding in Burkina Faso – FY20/Q3

Figure 8.b: HIV testing and case finding by HTS modality in Burkina Faso – FY20/Q3

21 • Index testing by country Togo The cascade of index testing in Q3 in Togo (Figure 9.a) shows that, index testing services were offered to 1,332 index cases among whom 1,160 index cases accepted the offer (87% of acceptance). 2,412 contacts were elicited among whom 30 were known HIV positive. 12.8% (309/2,412) of the contacts elicited declined the HIV testing. The HIV testing among contacts yielded by 1,385 new HIV negative and 688 new HIV positive with a seropositive rate of 33%. The offer of index testing is low compared to the number of individuals newly diagnosed HIV positive during the quarter. From those newly diagnosed HIV positive, only 43.2% (1,332/3,082) were offered index testing service. In quarter 4, the project team will reinforce the technical assistance to the sites in order to improve the index testing cascade.

Figure 9.a: Togo Cascade of index testing Q3/FY20

All HIV testing performed through Index testing were conducted with respect for confidentiality, consent, and the rights of clients. The passive referral (72%) was the most method of referral used in Togo during this quarter as shown in Figure 9.b. The proportion of index contacts referred through provider and contract referrals is low (18% et 4% respectively). In quarter 4, tailored technical assistance on the motivational interviewing (MI) will be planned for health care workers in Togo in order to improve their communication and counseling skills. The aim of this support is to increase the volume of index contacts referrals through provider and contact.

22 Figure 9.b: Index testing by referral methods Q3/FY20 in Togo

Burkina Faso The Figure 10.a illustrates the cascade of index testing in Quarter 3 in Burkina Faso. 367 index cases received index testing services among whom 314 index cases accepted. A total of 514 contacts were elicited among whom 6 known HIV positive. 22.4% (115/514) of the contacts elicited declined the HIV testing. 393 contacts tested for HIV and 126 were newly diagnosed HIV positive which represents a case finding of 32%. The index testing is not yet fully implemented in most of the supported sites in Burkina Faso. The index testing is only offered to PLHIV who are willing to accept their HIV status and who can consent to elicit contacts. Only 31.4% of the individuals newly diagnosed HIV positive (367/1,170) were offered index testing service. In quarter 4, health workers will be coached in the implementation of the motivational interviewing in order to increase the offer and the acceptance of the index testing services.

23 Figure 10.a: Burkina Faso Cascade of index testing Q3/FY20

As in Togo, the proportion of index contacts referred through provider referral (12%) is lower than the passive referral (84%) in Burkina Faso as shown in Figure 10.b. The technical assistance to health care workers on the motivational interviewing (MI) will be also planned for the improvement of health providers counseling skills. Thus, the volume of index contacts referrals through provider and contact will be increased.

Figure 10.b: Index testing by referral methods Q3/FY20 in Burkina Faso

24 • HTS by sites and by country Togo EVT (n= 2,247) and CHR Tsévié (n= 1,794) recorded the highest volume of HIV testing performed during this quarter in Togo (Figure 11.a). The maximum HIV positive individuals were diagnosed by the two sites also (321 for EVT and 230 CHR Tsévié). During this quarter, weekly performance review calls were organized with each supported site. These calls bring together the project team and the site staff to discuss weekly achievements against targets, the challenges in reaching the targets and the solutions and/or approaches to address the challenges. In quarter 4, monthly performance review with all the implementing sites will be organized in order to provide a platform of experience sharing within the project supported sites. Figure 11.a: HIV testing and case finding by sites in Togo – FY20/Q3

Burkina Faso In Burkina Faso, CM Oasis (n= 1,140) and CMA Hounde (n= 694) recorded the highest number of HIV testing performed during this quarter (Figure 11.b). The maximum number of HIV positive individuals were diagnosed by CMA Kossodo (n= 182), CM Oasis (n= 139) and DS Koudougou (n= 124). As in Togo, weekly sites performance review calls were also organized in Burkina Faso during this quarter. discussions during these calls are focused on weekly achievements, the challenges in reaching the targets and the solutions and/or approaches to address the challenges. In quarter 4, in-country monthly performance review with all the implementing sites will be organized in order to provide a platform of experience sharing within the project supported sites in Burkina Faso.

25 Figure 11.b: HIV testing and case finding by sites in Burkina Faso – FY20/Q3

• HIV testing and ART initiation by sub-awardee Togo As in the previous quarters (quarter 1 and quarter 2), CMS Lucia (EVT) diagnosed the highest number of HIV positive (n= 321) and individuals newly enrolled on ART (321) during this quarter. The overall linkage rate to ART is 96.8%. Most of the sites in Togo recorded a linkage rate to ART greater than 90% (Table 2.a). Only 12% (3 over 25) of the project’s sites in Togo recorded a linkage to ART rate less than 90%. These sites are: CHP Kpalimé (64.2%), CHR Atakpame (82.6%), and Hopital de Be (86.8%). All these sites are publics facilities and are reference hospitals that receive bedridden patients. However, these clients are kept in care while awaiting their recovery before enrolling them into ART.

Table 2.a: Overview of HIV testing and linkage to ART by sub-awardee in Q3/FY20 in Togo ART No Togo Sub-awardees HTS_TST HTS_TST_POS Yield TX_NEW linkage rate 1 Centre de Santé de Lomé 285 59 20.7% 53 89.8% 2 CHR Lome Commune 237 76 32.1% 71 93.4% 3 CMS Adakpamé 324 90 27.8% 100 111.1% 4 Crips-Togo 855 125 14.6% 130 104.0% 5 Action Contre Le Sida 746 147 19.7% 154 104.8%

26 ART No Togo Sub-awardees HTS_TST HTS_TST_POS Yield TX_NEW linkage rate 6 CMS Amoutivé 297 51 17.2% 55 107.8% 7 Hopital de Be 1,268 174 13.7% 151 86.8% 8 CMS Kodjoviakope 442 32 7.2% 35 109.4% 9 Jade Pour La Vie 638 103 16.1% 100 97.1% 10 CHU campus 805 81 10.1% 79 97.5% CMS Aide Médical et Charité 11 941 181 19.2% 166 91.7% (AMC) 12 CMS Confiance (FAMME) 1,209 147 12.2% 142 96.6% 13 CMS Lucia (EVT) 2,247 321 14.3% 321 100.0% 14 CMS AST Baguida 1,322 220 16.6% 219 99.5% 15 CMS Adidogomé 646 127 19.7% 122 96.1% 16 CMS Agoenyive 695 168 24.2% 154 91.7% 17 CMS Espoir Vie Vue (E2V) 393 68 17.3% 69 101.5% Centre Hospitalier Préfectoral 18 1,243 205 16.5% 201 98.0% Aného 19 CHP vogan 263 84 31.9% 76 90.5% CMS Soeurs de La Providence 20 889 203 22.8% 200 98.5% de Kouve 21 CHR Tsévié 1,794 230 12.8% 225 97.8% 22 Hopital de Notse 590 51 8.6% 47 92.2% 23 CHP Kpalime 555 53 9.5% 34 64.2% 24 CHR Atakpame 1,072 46 4.3% 38 82.6% 25 Polyclinique Atapkame 558 40 7.2% 40 100.0%

Togo Overall 20,088 20,314 15.2% 3,082 2,982

Burkina Faso In Burkina Faso, CMA Pissy and CM Oasis enrolled the highest number of patients on ART (153 and 136 respectively) during this quarter. By the end of quarter 3, the overall linkage to ART rate in Burkina Faso was 91.7%. Some sites in Burkina Faso such as CMA Pissy, CM Vie Positive, CM ALAVI, and CHU/CDG recorded a linkage rate to ART beyond 100% (Table 2.b). Most of the HIV positive diagnosed in quarter 2 by these sites and that were not enrolled on ART have been successfully put on ART in the course of this quarter. Some sites such as CMA Pissy and CHU/CDG are referral centers that receive HIV-positive clients diagnosed by surrounding facilities and referred for ART enrollment. Other facilities such as CMA Kossodo (52.2%), CM Yeleron (63.2%), DS Kossodo (69.4%), CM REVS+ (86.5%), and Yeleron+ (87.3%) recorded a linkage to ART rate less than 90%.

27 The project team will provide tailored technical assistance to the facilities with a low linkage to ART rate in the implementation of the test and start strategy.

Table 2.b: Overview of HIV testing and linkage to ART by sub-awardee in Q3/FY20 in Burkina Faso ART Burkina Faso Sub- No HTS_TST HTS_TST_POS Yield TX_NEW linkage awardees rate 1 CM Oasis 1,141 139 12.2% 136 97.8% 2 CM Samandin 280 38 13.6% 37 97.4% 3 Yerelon+ 484 63 13.0% 55 87.3% 4 CHU Bogodogo 505 90 17.8% 80 88.9% 5 CHU/CDG 141 17 12.1% 19 111.8% 6 CM Alavi 231 29 12.6% 55 189.7% 7 CM Vie Positive 346 44 12.7% 47 106.8% 8 CMA Pissy 466 119 25.5% 153 128.6% 9 CMA Kossodo 295 182 61.7% 95 52.2% 10 CMA Paul VI 513 60 11.7% 64 106.7% 11 DS Koudougou 156 124 79.5% 86 69.4% 12 CM Réo 423 57 13.5% 57 100.0% 13 CM Espoir et Vie 555 64 11.5% 57 89.1% 14 HDJ 118 55 46.6% 56 101.8% 15 CM REVS+ 325 37 11.4% 32 86.5% 16 CM Yérélon 204 19 9.3% 12 63.2% 17 CMA Houndé 702 33 4.7% 32 97.0% Burkina Faso Overall 6,885 1,170 17.1% 1,073 91.7%

• Key strategies for HIV testing, linkage and ART initiation During this quarter, supportive technical coaching was provided to health care workers to ensure an effective implementation of case finding strategies and also the implementation the test and start strategy at site level. The supportive coaching session provided to the sites contributed to the achievements of the HIV case finding and the linkage rate to ART obtained during this quarter despite of the advent the COVID- 19 disease. With the outbreak of the COVID-19 in the two countries, recovery plans are being implemented in both countries with a focus on community testing. Enhanced Peer Outreach Approach (EPOA) campaigns are also organized in both Togo and Burkina Faso. These campaigns target especially KPs.

28 To cope with the restrictions of traveling and triage at the entrance of facilities, weekly virtual coaching sessions and performance review were organized via Microsoft Teams and Zoom. The project also put an emphasis on the involvement of case managers as HIV counselors in the implementation of the test and start strategy. As HIV counselors, case managers are the first contact of HIV testing clients. They are responsible of the counseling before testing, the post-counseling and the announcement of the test results. Anyone who has been diagnosed HIV positive is directly linked to a case manager who ensures his linkage to care and to ART. In addition, the case managers oversee the tracking and tracing of defaulters ART patients and their re-engagement on ART.

Retention on ART and viral load suppression • Retention on ART At the end of this quarter, the project achieved 79% of the TX_CURR annual target in Togo and 95% in Burkina Faso. The e-tracker database developed by the project is set-up for each client tracking using a unique identification code. For patients on ART, the e-tracker provides information on those who are active and those who are defaulters and lost to follow-up. The key information used to monitor active ART patients and defaulters are: (i) the ARV refill dates, (ii) the number of months of dispensing, and (iii) the date of the next appointment. After two quarters of implementation of this database and with the volume of data entered, the project team detected some discrepancies in the formula of TX_CURR, TX_ML, TX_RTT and MMD. A technical workshop was organized with the consultant of the e-tracker in order to resolve this inconsistency and provide accurate values of the TX_CURR that correspond with the PEPFAR/ MER 2.0 definition and with the dynamic of this indicator.

Togo Based on the corrected formula made in the e-tracker, the accurate values of the TX_CURR for Togo have been provided for Q1 and Q2. In July, the project team will provide technical assistance to M&E staff and Data clerks at site level in order to ensure that TX_CURR data are submitted timely. Additional Data clerks will be recruited for the facilities with an active file greater than 1,000 ART patients. At the end of quarter 2, a total of 27,339 PLHIV had been cumulatively enrolled on ART and continuously followed-up at projects’ sub-awardees facilities. In this third quarter, 2,982 PLHIV (adults and children) were newly enrolled on ART in Togo. As of June 30, 2020, the project’s TX_CURR is 29,505 PLHIV achieving 79% of the annual target. The figure 12.a provides the overview of the trend in TX_NET_NEW from Q1 to Q3 of this fiscal year based on the corrected values of TX_CURR.

29 Figure 12.a: Trends in TX_NET_NEW from Q1 to Q3/FY20 in Togo

Burkina Faso

Based on the corrected formula made in the e-tracker, the accurate values of the TX_CURR of Burkina Faso at the end of quarter 2, is 21,260 PLHIV and 21,662 at the end of quarter 3. Quarter 3 TX_CURR data is still being updating into the e-tracker. In Burkina Faso, a total of 1,073 individuals were newly enrolled on ART during this quarter with a TX_NET_NEW of 402. The figure 12.b provides an overview of the trend in TX_NET_NEW from Q1 to Q3 of this fiscal year based on the new values of TX_CURR as corrected in the e-tracker.

Figure 12.b: Trends in TX_NET_NEW from Q1 to Q3/FY20 in Burkina Faso

30 • Viral load suppression Togo The viral load data have been extracted from national electronic database of the laboratory information system in order to minimize viral load data collection errors. Only the sites supported by the project data have been extracted. From July 2019 to June 2020, the total number of ART patients with a viral load result documented in the laboratory records was 8,354 among whom 82% (n= 6,847) had a suppressed viral load result (<1,000 copies/ml). Only 36% of eligible ART patients did a test of viral load with a documented result (Figure 13.a). There are several stock-out of viral load tests and reagents that impacts also the demand and the coverage of viral load. The TX_PVLS recorded in Togo at the end of this quarter (82%) is less than the target of 85% assigned by the donor. In quarter 4, the project team will provide supportive assistance to the facilities in providing adherence support to the unsuppressed patients. Figure 13.a: Togo Cascade of viral load testing and suppression Q3/FY20

Burkina Faso The viral load data was also extracted from the national electronic laboratory database for the sites supported by the project in Burkina Faso with a completeness of 35% of the projects’ sites. Based on the viral load data received, there was viral load documented result for 1,383 ART patients from July 2019 to June 2020. Only 7% of eligible ART patients did a test of viral load with a documented result in Burkina Faso (Figure 13.b). The Percentage of ART patients with a suppressed viral load result (<1000 copies/ml) in Burkina Faso by the end of quarter 3 was 79% (n= 1,094). The project team will provide supportive assistance to the facilities in providing adherence support to the unsuppressed patients.

31 As in Togo, the big issue to address is related to the stock-out of viral load tests and reagents that impacts also the demand and the coverage of viral load. This issue is not under the control of the project team.

Figure 13.b: Burkina Faso Cascade of viral load testing and suppression Q3/FY20

• Key strategies for ART retention and adherence support Strategies deployed for retention and adherence on ART include: (1) differentiated follow-up and home visits conducted by case managers; (2) individual and/or group counseling on treatment adherence organized by health providers; (3) appointment reminders through SMS and phone calls or home visits by case managers; and (4) the introduction of the community and home based ARV refill through case managers during the outbreak of the COVID-19. During next quarter, the project will continue to provide support to facilities by extracting the lists of ART patients expected for ARV refill for reminders and the list of defaulters for recalls. The #EAWA project will recruit and involve additional case managers and peer navigators in order to improve the case management.

Full cascade of prevention, care and treatment The full cascade of prevention, care and treatment is therefore presented as follows in each of the two countries:

32 Figure 14.a: Togo Cascade of prevention, care and treatment in Q3/FY20

Figure 14.b: Burkina Faso Cascade of prevention, care and treatment in Q3/FY20

33 Trend of key performance indicators from Q1 to Q3 From quarter 2 to quarter 3 of this fiscal year 20, the number of the HIV case finding (HTS_TST_POS), the yield and the number of HIV positive newly enrolled on ART (TX_NEW) decreased in Togo (Figure 14.a). The linkage to ART rate increased for 95% in Q2 to 97% in Q3. The TX_CURR is increasing quarter to quarter from 25,459 in Q1 to 27,339 in Q2 and 29,505 in Q3. Figure 14.a: Trend of key performance indicators from Q1 to Q3/FY20 in Togo

In Burkina Faso, the HTS_TST, HTS_TST_POS and TX_NEW increased during this quarter compared to quarter 2 (Figure 14.b). The ART linkage rate decreased from 107% in Q1 to 96% in Q2 and 92% in Q3. Figure 14.b: Trend of key performance indicators from Q1 to Q3/FY20 in Burkina Faso

34 Impact of the COVID-19 in achievements of project targets The outbreak of the COVID-19 disease in March 2020 impacted negatively the implementation of the project and the progress towards the achievement of annual targets in both Togo and Burkina Faso. The further implementation of the recovery plan with sustained results in quarter 4 will help mitigate the impact of the COVID 19 in both countries. COVID-19 impact in Togo Without the COVID-19 disruption, the project should have achieved by the end of Q3 73% of the HTS_TST_POS and 59% of the TX_NEW annual targets in Togo. If the results of the implementation of the recovery plan recorded in June 2020 are sustained in Q4, the project will achieve 99% of the HTS_TST_POS and 82% of the TX_NEW annual targets at the end of FY 20 (Figures 15.a & 15.b). Figure 15.a: Impact of COVID-19 on Q3 performances and FY20 projection for HTS_TST_POS in Togo

Figure 15.b: Impact of COVID-19 on Q3 performances and FY20 projection for TX_NEW in Togo

COVID-19 impact in Burkina Faso Without the COVID-19 disruption, the project should have achieved by the end of Q3 76% of the HTS_TST_POS and 68% of the TX_NEW targets in Burkina Faso. If the results of the implementation of the recovery plan recorded in June 2020 are sustained in Q4, the project will achieve 102% of the HTS_TST_POS and 90% of the TX_NEW targets at the end of FY 20 (Figures 16.a & 16.b).

35 Figure 16.a: Impact of COVID-19 on Q3 performances and FY20 projection for HTS_TST_POS in Burkina Faso

Description of results achieved under the KPIF project

KPIF achievements in Togo The Key populations investment fund (KPIF) project started field activities in Togo in February 2020 with four subawards, two with community clinics: FAMME and EVT; and two with KP-led partners: AFAZ and Reseau Cupidon. During this quarter, a total of 2,244 individuals KPs were newly reached in Togo via the KPIF project including 694 FSW and 1,540 MSM. 91% (1,766/1,945) of those eligible (newly tested and/or referred plus declined for HTS) were tested for HIV, 12% were diagnosed HIV positive, and all were linked to ART. Considering annual targets, KPIF achieved by the end of Q3 FY20 in Togo, 83% of the target of KP_PREV, 67% for HTS_TST, 58% for HTS_TST_POS and 64% for TX_NEW (Figure 17).

36 Figure 17: Cumulative Cascade for Key Populations of KPIF Togo for FY20 Year to Date

Performances across the HIV cascade among MSM and FSW by IPs are as follow in Table 3:

Table 3: Cumulative performance by IPs for FY20 up to June 2020 Key Populations of KPIF Togo Indicators KP_PREV HTS_TST HTS_TST_POS TX_NEW KPIF TOGO # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative FAMME 1,000 1,070 107% 871 678 78% 113 79 70% 102 79 77% AFAZ 516 444 86% 450 349 78% 58 39 67% 53 39 74% TOTAL FSW* 1,469 1,514 103% 1,280 1,027 80% 166 118 71% 150 118 79% EVT 2,000 1,495 75% 1,648 1,050 64% 264 150 57% 237 150 63% CUPIDON 1,281 850 66% 1,055 536 51% 169 70 41% 152 70 46% TOTAL MSM/TG* 3,164 2,345 74% 2,607 1,586 61% 417 220 53% 375 220 59% TOTAL KP* 4,633 3,859 83% 3,887 2,613 67% 583 338 58% 525 338 64%

*USAID Target

The FSW program in Togo had a strong cumulative performance at the end of Q3, with an achievement level of 103%, 80%, 71%, and 79% for KP_PREV, HTS_TST, HTS_TST_POS, and TX_NEW, respectively. The MSM program, which had a strong overall cascade with 14% case finding and 100% of ART initiation rates, didn’t hit the expected benchmark of 66%, excepted KP_PREV (74%).

37 KPIF achievements in Burkina Faso The Key populations investment fund (KPIF) project started field activities in Burkina Faso in April 2020 with three subawards: Yeleron+, Espoir et Vie and AAB. During this quarter, a total of 1,440 individuals KPs were newly reached in Burkina Faso via the KPIF project including 1,275 FSW and 165 MSM. 88% (1,270/1,440) of those eligible (newly tested and/or referred plus declined for HTS) were tested for HIV, 10% were diagnosed HIV positive, and 94% (n=125) were linked to ART (Figure 1). Considering annual targets, KPIF achieved by the end of Q3 FY20 in Burkina Faso, 47% of the target of KP_PREV, 47% for HTS_TST, 46% for HTS_TST_POS and 48% for TX_NEW (Figure 18). Figure 18: Cumulative Cascade for Key Populations of KPIF Burkina Faso for FY20 Year to Date

Performances across the HIV cascade among MSM and FSW by IPs are as follow in Table 4:

Table 4: Cumulative performance by IPs for FY20 up to June 2020 Key Populations of KPIF Burkina Faso Indicators

KPIF Burkina Faso KP_PREV HTS_TST HTS_TST_POS TX_NEW # Achieved # Achieved # Achieved # Achieved Target % Target % Target % Target % Cumulative Cumulative Cumulative Cumulative YERELON Plus 1,500 420 28% 1,316 250 19% 145 30 21% 130 30 23% EV (FSW) 1,088 855 79% 954 855 90% 105 86 82% 94 78 83% TOTAL FSW 2,588 1,275 49% 2,270 1,105 49% 250 116 46% 224 108 48% AAB NA NA NA NA NA NA NA NA NA 38 17 45% EV (MSM) 473 165 35% 422 165 39% 42 17 40% NA NA NA TOTAL MSM 473 165 35% 422 165 39% 42 17 40% 38 17 45% TOTAL KP 3,061 1,440 47% 2,692 1,270 47% 292 133 46% 262 125 48%

38

The FSW program had better cumulative performance than MSM program at the end of Q3. The performance benchmark was 50 percent based on a two-quarter implementation period for FY20. FSW IP achieved 49%, 49%, 46%, and 48% for KP_PREV, HTS_TST, HTS_TST_POS, and TX_NEW, respectively. MSM program, which had a better overall cascade with 10% case finding and 100% ART initiation rates, didn’t hit the 50% benchmark.

Implementation of the Environmental Monitoring and Mitigation Plan (EMMP)

During this quarter, 5,237 key populations (1,796 in Burkina Faso and 3,441 in Togo) have been reached with HIV prevention interventions designated for the target population. All these KPs have been sensitized on the proper management of waste condoms and lubricants. Details on the implementation of the EMMP are provided in the stand-alone annexes.

Protecting Life in Global Health Assistance (PLGHA)

FHI360 has adhered to the “Protecting Life in Global Health Assistance” policy adopted by the US government as it applies to non-governmental organizations (NGOs) that receive U.S. funding for global health assistance. The policy requires foreign NGOs to agree, as a condition of receiving global health assistance that they will not perform or actively promote abortion as a method of family planning. This policy encompasses all global health programs, including, among other programs, HIV/Aids. To that effect, #EAWA team continuously ensured that all its sub-awardees comply with PLGHA policy. At the beginning of the program, all sub-awardees have filled a due diligence checklist on PLGHA and adhered to the PLGHA policy by signing an abortion prohibition clause as part of their grant agreement.

39 Section 3. Discussion of challenges to implementation The table 4 provides an overview of key challenges to project’s implementation and proposed solutions. Table 5: Key challenges to project’s implementation Challenges/difficulties Solutions Prevention Stock-out of STI kits and HIV test (“First Discussion has been engaged with national response”) stakeholders (PNLS, PSSLS, FTO and PSM) in order to address this challenge Case finding - Several stock-out for HIV test (“First - Discussion has been engaged with the PNLS in response”) in Togo Togo and PSSLS in Burkina Faso in order to address this challenge as the purchase of commodities is not allowed on this project. - Continuous discussions have been engaged with FTO in Togo and PSM in Burkina Faso regarding RTK stock

- Decrease of HIV case finding within the - Start the implementation of HIV self-testing in context of the COVID-19 Togo and advocacy of the introduction of HIV self-testing in Burkina Faso - Reinforce the implementation of Index Testing by regular coaching and supportive technical assistance - Continue the implementation of the recovery plan during Q4 in both countries

Treatment and - Stock-out of ARV - Continuous discussions have been engaged retention on with FTO in Togo and PSM in Burkina Faso

ART regarding ARV stock-out

- Only few ART patients are receiving MMD - Use the e-tracker to support sites in the 3-5 months and none on MMD 6+ months. identification of the eligible MMD patients. - Advocate with the NACP for the implementation of MMD 6

Viral load - Stock-out of viral load reagents - Advocate with the NACP and other relevant testing - There are delays in the provision of viral stakeholders for viral load reagents supply load results in both countries - Advocate with the NACP in order to reduce delays in providing viral load results,

- Recruitment of data entry agents to speed up

data entry in viral load laboratories.

- Involvement of peer navigators in the viral - Low coverage and poor access to viral load load management in order to increase the demand

40

Monitoring of key assumptions ▪ Political stability: Since the end of 2017, Togo has been witnessing political demonstrations that sometimes disrupt public order. From January to February 2020, the country organized presidential election. Political demonstrations during this election period disrupted the smooth running of project activities in the country. Burkina Faso is facing attacks by jihadist groups that affect the security situation in several parts of the country. These attacks resulted in the displacement of people and restrictions in travelling to some projects sites in order to provide technical support.

▪ Commitment of the various countries’ ministries of health, their National AIDS Control Committees/Programs to support program implementation: During this quarter, the Ministry of Health (through the PNLS and PSSLS) and the CNLS in both Burkina Faso and Togo have demonstrated their commitment to project activities by actively organizing monthly meetings of the steering committee of the project in both countries. In Togo, the PNLS is acting as a main technical partner of the project with responsibilities in national supervision, quality control, training, and lab strengthening activities .The monthly steering committee meetings were held regularly under the heading of CNLS with the participation of all key stakeholders to discuss the overall program implementation and address bottlenecks. In Burkina, the framework of collaboration with the PSSLS was finalized, and a consensus was reached on the operationalization of the program steering committee with USAID and the SP/CNLS.

▪ COVID-19 pandemic: Since March 2020, the COVID-19 pandemic is impacting the implementation of the project activities. In both countries (Burkina Faso and Togo), a triage system has been introduced at the entrance of health facilities and limits access to clients. This measure is affecting HIV testing occurring in facilities such as VCT, index testing and other PITC. In some sites, health care workers assigned to the project has been redeployed to COVID-19 patient management sites. This affects the provision of HIV screening services, as well as PLHIV care and treatment services. A few of #EAWA partner tertiary hospitals are designated as referral points for the management of suspected and confirmed COVID-19 cases. Other sites were designated as treatment and care centers for COVID-19 patients. This has created disruption in the continuum of services. This has also meant that patient traffic flow within and outside the hospital, including workforce and other resources, were drastically disrupted. The lack of personal protection equipment has impaired the ability of health workers to provide HIV services in clinical settings, but also discouraged community workers in engaging in community activities.

A contingency plan has been developed to mitigate the COVID-19 impact on the continuation of operations.

The project has demonstrated resilience towards the pandemic as suggested by the adverse impact of performance, in both Togo and Burkina Faso, that has been largely mitigated

41 through implementation of adaptative measures and innovative strategies discussed in this report. The close collaboration with national stakeholders since the beginning of the pandemic to tackle key challenges has also been pivotal in laying the ground for a resilient ecosystem despite the constraining factors brought about by the COVID-19 situation.

Section 4. Activities planned for next quarter Major activities planned for the next quarter are described as follows: - Implementation of a contingency plan to continue operations under the context of COVID- 19; - Training of new peer educators in Burkina Faso and in Togo on peer education and motivational interview; - Continued technical supervision and coaching on technical approaches of case finding, documentation of index testing, retention, and viral load testing; - Continued collaboration with organizations and authorities along the supply chain to address bottlenecks; - Organization of monthly steering committee meetings in both countries; - Organization of coordinating meeting with project supported health facilities in Togo and in Burkina Faso; - Training of M&E staff and data clerks of supported sites in Burkina Faso on E-Tracker platform, data collection and reporting tools; - Implementation of the HIV self-testing in Togo; - Advocacy with the NACP for the introduction of HIV self-testing in Burkina Faso.

42 Section 5. Financial brief 1-Obligated amount The award Modification # 5 was fully executed on December 17, 2019 to provide an incremental funding in the amount of $8,683,979.00 and increase the project total obligated amount from $5,823,662.00 to $14,507,641.00.

2- Expenditures for Q3 FY20 and Cumulative Expenditures During the period under review (see table below), the total project expenditures amounted to $2,211,305 which represents a 98% increase compared to $1,113,045 total expenditures incurred during Q2FY2020 and 487% more compared to Q1FY20 incurred expenditures ($376,657).

Cumulatively, the contract to date actuals ($9,042,910) represent 62% of the project total obligated amount ($14,507,641.00). With three months to go on the fiscal year, the current obligation remaining balance is $5,464,731 which represents 38% of the cumulative obligation amount.

Compared to PEPFAR FY2020 budget ($8,683,979), we have consumed $3,701,007 over the three first quarters of the fiscal year which represent 42.6% of the project Year 3 budget.

43 #EAWA PIPELINE AS OF JUNE 30, 2020 Total Cumulative Expenditures Expenditures Cumulative Remaining Total % Projected Total Award Obligated FY20 PEPEFAR Expenditures Expenditures Jan - Mar Apr - Jun Expenditures FY2020 Remaining Obligation Expenditures Item Description Budget Budget Budget as of Sep. 2019 Oct - Dec 2019 2020 2020 thru Jun 2020 Budget Obligation Spent Q4 FY2020

I. Salaries $ 4,926,836 $ 2,657,129 $ 1,590,502 $ 1,121,243 $ 159,758 $ 176,758 $ 305,825 $ 1,763,585 $ 948,160 $ 893,544 66% $ 305,825.00

II. Fringes $ 2,137,827 $ 1,152,968 $ 690,144 $ 356,969 $ 61,588 $ 72,486 $ 115,625 $ 606,668 $ 440,445 $ 546,300 53% $ 115,625.00

III. Consultant $ 541,261 $ 291,912 $ 174,733 $ 22,395 $ 9,397 $ 8,334 $ 9,637 $ 49,763 $ 147,365 $ 242,149 17% $ 181,126.45

IV. Travel & Transportation $ 1,211,074 $ 653,153 $ 390,964 $ 403,786 $ 21,483 $ 22,997 $ 14,107 $ 462,374 $ 332,376 $ 190,779 71% $ 177,680.53

V. ODCs $ 4,328,451 $ 2,334,409 $ 1,397,329 $ 1,068,281 $ (103,563) $ 115,244 $ 601,542 $ 1,681,504 $ 784,106 $ 652,905 72% $ 413,284.11

VI. Other Pass through $ 12,207 $ 664 $ (6,346) $ 335 $ 6,860 $ 5,347 $ (6,860) 0% $ -

VII. Equipment & Commodities $ 385,702 $ 208,016 $ 124,514 $ 42,411 $ 204,519 $ 62,587 $ 11,990 $ 321,507 $ (154,582) $ (113,491) 155% $ 121,183.45

VIII. Subcontract & Subawardees$ 8,378,354 $ 4,518,593 $ 2,704,739 $ 1,258,143 $ (31,063) $ 454,926 $ 737,172 $ 2,419,178 $ 1,543,704 $ 2,099,415 54% $ 1,468,601

TOTAL DIRECT COSTS $ 21,909,505 $ 11,816,180 $ 7,072,925 $ 4,285,436 $ 322,783 $ 906,987 $ 1,796,233 $ 7,311,439 $ 4,046,922 $ 4,504,741 62% $ 2,783,325

IX. G&A $ 4,677,145 $ 2,522,466 $ 1,509,897 $ 1,014,533 $ 55,035 $ 189,060 $ 387,501 $ 1,646,130 $ 878,301 $ 876,336 65% $ 411,748.94

X. SSM $ 313,350 $ 168,995 $ 101,157 $ 41,935 $ (1,162) $ 16,998 $ 27,570 $ 85,341 $ 57,751 $ 83,654 50% $ 54,926

TOTAL INDIRECT COSTS $ 4,990,495 $ 2,691,461 $ 1,611,054 $ 1,056,468 $ 53,874 $ 206,057 $ 415,072 $ 1,731,471 $ 936,051 $ 959,990 64% $ 466,674

XI. GRAND TOTAL $ 26,900,000 $ 14,507,641 $ 8,683,979 $ 5,341,904 $ 376,657 $ 1,113,044 $ 2,211,305 $ 9,042,910 $ 4,982,973 $ 5,464,731 62% $ 3,250,000

Additional Notes and Comments:

44 - Historical project Burn Rate: $271,408 - Current Quarter Burn Rate: $737,102 - Previous Quarter Burn Rate: $371,015

Due to a slow start the project has been facing throughout the previous quarters, we have been working on an ambitious goal to consume at least 80% of the above PEPFAR project budget for FY20. As such, a rigorous procurement and sub- awardee cash disbursement planning are being monitored on a weekly basis. Likewise, program activities and recurring project costs have been assessed and regularly monitored to accommodate the above 80% goal.

3- Subgrantees Disbursements (Q3 FY2020) and cumulative

The table below summarizes the disbursements made in Q3 FY20 to the Implementing Partners.

N# Disbursements made in Q3 FY20 to Country Funds Cumulative Started Date Completion the Implementing Partners as per Disbursed Disbursements Date the summary table below including in FY20 as June 30, 2020 cumulative disbursements: 1 Vie Positive Burkina Faso 35,622.46 35,622.46 10/1/2019 7/31/2021 2 EV Burkina Faso 9,749.25 9,749.25 10/1/2019 7/31/2021 3 ALAVI Burkina Faso 43,603.32 43,603.32 10/1/2019 7/31/2021 4 AAS Burkina Faso 60,326.80 173,650.70 6/12/2018 7/31/2022 5 REV+ Burkina Faso 52,047.91 93,864.19 6/12/2018 7/31/2022 6 YERELON+ Burkina Faso 8,842.53 27,653.00 1/4/2019 7/31/2022 7 CLINIQUE YERELON Burkina Faso 21,229.01 21,229.01 10/1/2019 9/30/2020 8 CMA PISSY Burkina Faso 29,762.68 29,762.68 10/1/2019 9/30/2020 9 CMA KOSSODO Burkina Faso 9,328.29 9,328.29 10/1/2019 9/30/2020 10 CMA PAUL VI Burkina Faso 27,481.67 27,481.67 10/1/2019 9/30/2020 11 HDJ BOBO Burkina Faso 42,432.60 42,432.60 10/1/2019 9/30/2020 12 CHU BOGODOGO Burkina Faso 38,505.14 38,505.14 10/1/2019 9/30/2020 13 CMA KDGOU Burkina Faso 16,714.35 16,714.35 10/1/2019 9/30/2020 14 CMU SAMANDIN Burkina Faso 22,414.75 22,414.75 10/1/2019 9/30/2020 15 CMA REO Burkina Faso 17,921.80 17,921.80 10/1/2019 9/30/2020 16 CMA CDGP Burkina Faso 8,643.89 8,643.89 10/1/2019 9/30/2020

45 17 CMA HOUNDE Burkina Faso 8,046.42 8,046.42 10/1/2019 9/30/2020 18 EVT Togo 127,633.54 252,381.34 6/22/2018 7/31/2022 19 FAMME Togo 65,406.74 228,500.32 6/19/2018 7/31/2022 20 CRIPS Togo 36,810.89 36,810.89 10/1/2019 7/31/2021 21 ACS Togo 65,326.18 65,326.18 10/1/2019 7/31/2021 22 AMC Togo 58,415.67 58,415.67 10/1/2019 7/31/2021 23 AST Togo 47,407.05 47,407.05 10/1/2019 7/31/2021 24 E2V Togo 45,794.85 45,794.85 10/1/2019 7/31/2021 25 Jade Pour La Vie Togo 46,708.03 46,708.03 10/1/2019 7/31/2021 26 CMS KOUVE Togo 67,198.67 67,198.67 10/1/2019 7/31/2021 27 CHP Aneho Togo 26,188.76 26,188.76 10/1/2019 9/30/2020 28 CMS Amoutieve Togo 11,291.61 11,291.61 10/1/2019 9/30/2020 29 CHR LC Togo 16,993.47 16,993.47 10/1/2019 9/30/2020 30 CMS Adidogome Togo 26,377.72 26,377.72 10/1/2019 9/30/2020 31 Hopital de Be Togo 27,536.25 27,536.25 10/1/2019 9/30/2020 32 CHR Tsevie Togo 23,508.43 23,508.43 10/1/2019 9/30/2020 33 Polyclinique Atakpame Togo 15,419.83 15,419.83 10/1/2019 9/30/2020 34 Centre de Sante Lome Togo 14,917.82 14,917.82 10/1/2019 9/30/2020 35 CMS Kodjoviakope Togo 17,890.13 17,890.13 10/1/2019 9/30/2020 36 CMS AGOE Togo 19,796.12 19,796.12 10/1/2019 9/30/2020 37 CS Adakpame Togo 19,164.38 19,164.38 10/1/2019 9/30/2020 38 PLNS Togo 60,133.14 60,133.14 10/1/2019 9/30/2020

4- Next Quarter Projections (Q4 FY2020)

#EAWA Q4 FY2020 PROJECTIONS Item Description Total Award Total Obligated FY2020 Budget Projected Expenditures Budget Budget Q4 FY2020

I. Salaries 4,926,836 2,657,129 1,590,502 305,825

46 II. Fringes 2,137,827 1,152,968 690,144 115,625

III. Consultant 541,261 291,912 174,733 181,126

IV. Travel & Transportation 1,211,074 653,153 390,964 177,681

V. ODCs 4,328,451 1,397,329 1,397,329 413,284

VI. Other Pass through

VII. Equipment & Commodities 385,702 124,514 124,514 121,183

VIII. Subcontract & Sub-awardees 8,378,354 4,518,593 2,704,739 1,468,601

TOTAL DIRECT COSTS 21,909,505 11,816,180 7,072,925 2,783,325

IX. G&A 4,677,145 2,522,466 1,509,897 411,749

X. SSM 313,350 168,995 101,157 54,926

TOTAL INDIRECT COSTS 4,990,495 2,691,461 1,611,054 466,674

XI. GRAND TOTAL 26,900,000 14,507,641 8,683,979 3,250,000

We are projecting 3,250,000 to be spent in the next quarter which represent an unaverage monthly burn rate of $1,083,333.

47 5- Next Quarter Subgrantees Planned Disbursement (Q4 FY2020)

N# Subgrantees Names Country Planned Started Date Completion Date Disbursement Q3 FY20 1 Vie Plus Burkina Faso 40,379.40 10/1/2019 7/31/2021 2 EV Burkina Faso 30,614.65 10/1/2019 7/31/2021 3 ALAVI Burkina Faso 54,533.14 10/1/2019 7/31/2021 4 AAS Burkina Faso 99,524.89 6/12/2018 7/31/2022 5 REV+ Burkina Faso 67,450.13 6/12/2018 7/31/2022 6 YERELON+ Burkina Faso 17,723.32 1/4/2019 7/31/2022 7 CLINIQUE YERELON Burkina Faso 21,580.28 10/1/2019 9/30/2020 8 CMA PISSY Burkina Faso 43,748.46 10/1/2019 9/30/2020 9 CMA KOSSODO Burkina Faso 25,596.19 10/1/2019 9/30/2020 10 CMA PAUL VI Burkina Faso 32,010.12 10/1/2019 9/30/2020 11 HDJ BOBO Burkina Faso 28,272.53 10/1/2019 9/30/2020 12 CHU BOGODOGO Burkina Faso 41,327.31 10/1/2019 9/30/2020 13 CMA KDGOU Burkina Faso 20,133.50 10/1/2019 9/30/2020 14 CMU SAMANDIN Burkina Faso 21,583.24 10/1/2019 9/30/2020 15 CMA REO Burkina Faso 20,689.67 10/1/2019 9/30/2020 16 CMA CDGP Burkina Faso 16,324.40 10/1/2019 9/30/2020 17 CMA HOUNDE Burkina Faso 18,286.58 10/1/2019 9/30/2020 18 EVT Togo 59,902.66 6/22/2018 7/31/2022 19 FAMME Togo 31,293.56 6/19/2018 7/31/2022 20 CRIPS Togo 59,515.78 10/1/2019 7/31/2021 21 ACS Togo 66,348.57 10/1/2019 7/31/2021 22 AMC Togo 48,211.21 10/1/2019 7/31/2021 23 AST Togo 67,195.17 10/1/2019 7/31/2021 24 E2V Togo 18,682.87 10/1/2019 7/31/2021

48 25 Le JADE pour la Vie Togo 30,818.94 10/1/2019 7/31/2021 26 CMS Kouve Togo 75,355.53 10/1/2019 7/31/2021 27 Hopital de Be Togo 19,642.45 10/1/2019 9/30/2020 28 Polyclinique Atakpame Togo 16,288.16 10/1/2019 9/30/2020 29 CMS Adidogome Togo 21,645.48 10/1/2019 9/30/2020 30 Amoutieve Togo 7,903.60 10/1/2019 9/30/2020 31 CHR Tsevie Togo 23,800.60 10/1/2019 9/30/2020 32 CMS Kodjoviakope Togo 13,551.98 10/1/2019 9/30/2020 33 CMS Adakpame Togo 11,029.55 10/1/2019 9/30/2020 34 CHP Aneho Togo 19,171.87 10/1/2019 9/30/2020 35 Centre de Sante de Lomé Togo 22,032.10 10/1/2019 9/30/2020 36 CHR Lomé Commune Togo 13,990.17 10/1/2019 9/30/2020 37 CMS Agoe Togo 15,626.05 10/1/2019 9/30/2020 38 PNLS Togo 73,420.56 10/1/2019 9/30/2020

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