Clinical & Community HIV & AIDS Services Strengthening (CHASS)

Quarter 2, FY17 Progress Report

LIFE OF PROJECT SUMMARY

Implementing Partner: Family Health International (FHI 360)

Activity Name: Clinical and Community HIV/AIDS Services Strengthening (CHASS) Project

Activity Goal: CHASS’s goal is to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in four provinces.

Activity Objectives: To contribute toward HIV/AIDS epidemic control in Mozambique, CHASS seeks to:

1) Increase coverage of antiretroviral treatment (ART) to 90 percent. 2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively. 3) Increase the average CD4 count at initiation of ART from 350 to 500 cells per cubic millimeter. 4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB. 5) Operationalize viral load testing. Life of Activity (start and end dates): August 2010–July 2018

Total Estimated Contract/Agreement Amount: US$137,982,152[1]

Total Amount Obligated (to date): US$115,310,555.00

Current Pipeline Amount: US$24,573,149

Actual Expenditure through This Quarter: US$79,120,423

Estimated Expenditures Next Quarter: US$24,573,149

Geographic Focus: Niassa, Tete, Manica, and Sofala Provinces, Mozambique

Report Submitted by: Dr. Joaquim Fernando

Submission Date: May 8, 2017

[1] After de-obligation of funding for voluntary medical male circumcision. 2 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Contents LIST OF FIGURES ...... 6 LIST OF TABLES...... 7 LIST OF ACRONYMS AND ABBREVIATIONS ...... 8 EXECUTIVE SUMMARY ...... 10 PROJECT OVERVIEW ...... 14 PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA ...... 16 IR1: STRENGTHEN FACILITY-BASED HIV SERVICES ...... 16 HIV Testing and Counseling ...... 16 Performance in counseling and testing ...... 16 Variation by geographic area ...... 19 Performance against HTC targets ...... 19 Challenges related to HTC ...... 21 Key HTC activities for the next quarter ...... 21 Care and Treatment ...... 21 Performance in care and treatment ...... 22 Variation by geographic area and interventions ...... 25 Performance against care and treatment targets ...... 28 Challenges related to care and treatment ...... 28 Key care and treatment activities in the next quarter ...... 29 Pediatric Antiretroviral Therapy ...... 29 Performance in pediatric care and treatment ...... 30 Variation by geographic area and Intervention ...... 31 Performance against pediatric care and treatment targets ...... 31 Challenges related to pediatric care and treatment ...... 32 Key pediatric care and treatment activities for the next quarter ...... 32 Laboratory Services ...... 32 Performance in lab testing ...... 32 Challenges related to lab ...... 33 Key lab activities for the next quarter ...... 33 Pharmaceutical Care Systems and Services ...... 33 Strengthening drug and commodity management ...... 34 Decentralization of ARV drug distribution and dispensing ...... 35 Support for the three-month dispensing initiative ...... 35 Strengthening the use of FILAs to identify and track defaulters ...... 36 Promoting and supporting pharmacovigilance and patient safety ...... 37 National-level pharmacy-related activities ...... 37 Key pharmacy activities for the next quarter ...... 38 Prevention of Mother-to-Child Transmission ...... 38 Performance in PMTCT ...... 39 Variation by geographic area and Intervention ...... 41 Performance against PMTCT targets ...... 42 Challenges related to PMTCT ...... 43 Key PMTCT activities for the next quarter ...... 43

3 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

TB/HIV Integration ...... 43 Performance in TB/HIV Integration ...... 44 Variation by geographic area and Intervention ...... 45 Performance against TB/HIV targets ...... 46 Challenges related to TB/HIV ...... 46 Key TB/HIV activities for the next quarter ...... 46 Nutrition Support ...... 46 Challenges related to nutrition ...... 47 Key nutrition activities planned for next quarter ...... 47 Gender ...... 47 Performance in GBV ...... 49 Challenges related to gender ...... 49 Key gender activities for the next quarter ...... 50 Health System Strengthening ...... 50 Governance and leadership at DPS, SDMAS, and HF levels ...... 50 Logistics supply chain management ...... 51 Financial management ...... 52 Human resources for health ...... 52 Private-public partnerships ...... 53 Quality Improvement ...... 53 Key quality improvement activities for next quarter ...... 54 IR2: STRENGTHEN COMMUNITY-BASED HIV SERVICES – ACCESS, QUALITY, AND RETENTION ...... 55 Community Services to Support Retention ...... 55 Household visits ...... 55 Strengthening technical capacity of CBOs ...... 57 Village savings and loan clubs ...... 57 Community Counseling and Testing ...... 58 Variation by geographic area ...... 59 Challenges Related to Community Activities ...... 62 Key Community Activities in the Next Quarter ...... 63 IR3: STRENGTHENED REFERRAL/LINKAGE SYSTEMS BETWEEN COMMUNITY AND FACILITY-BASED SERVICES ...... 64 Facilitated Linkages between C-HTC and HF Care and Treatment ...... 64 Referrals ...... 64 Defaulter Tracing ...... 65 Challenges Related to Community-Facility Linkages ...... 67 Key Community-Facility Linkages Activities in the Next Quarter ...... 67 STRATEGIC INFORMATION ...... 68 Electronic Patient Tracking System ...... 68 Optical Character Recognition Pilot...... 70 Internal M&E Strengthening ...... 71 Community data systems ...... 71 Data use ...... 72

4 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

PROJECT MANAGEMENT AND IMPLEMENTATION ...... 73 Sub-agreement management with DPS...... 73 Sub-agreement Management with SDSMAS ...... 73 Sub-agreement Management with CBOs ...... 74 Technical Assistance ...... 74 Capacity Building for CBOs ...... 74 Challenges related to Programs ...... 75 Key Programs activities for the next quarter ...... 75 Security and site accessibility ...... 75 MAJOR PRIORITIES/ACTIVITIES PLANNED FOR NEXT QUARTER ...... 78 ANNEXES ...... 79 Annex 1. Sites not accessible for data collection in FY17 Q2 due to flooding ...... 79 Annex 2. Provincial ART cascades, FY17 Q2 ...... 80 Annex 3. Number of participants in CHASS commodity management training by province and type of participant ...... 82 Annex 4. Health facilities receiving commodity management training in FY17 Q2 ...... 82 Annex 5. Facilities Receiving Support for the Management of Pharmacy-based Records, FY17 Q2 . 82 Annex 6. HF Level Management Strengthening Intervention Package...... 83 Annex 7. Progress Toward Strengthening District Logistics Systems, FY17 Q2 ...... 83 Annex 8. In-Service Training, FY17 Q2 ...... 84

5 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

LIST OF FIGURES Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q2...... 10

Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q2 ...... 11

Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and facilities providing ART services, FY17 Q2 ...... 15

Figure 4. HIV positivity yield by sector and quarter, over the past year ...... 18

Figure 5. Performance against target in HTC, by sector, FY17 Q2 ...... 20

Figure 6. ART cascade, FY17 Q2...... 22

Figure 7. Number of patients newly enrolled in ART by quarter and province, FY17 ...... 23

Figure 8. 12-month retention rates at SAPR 17, by province ...... 24

Figure 9. Twelve-month retention rates by district, APR16 and SAPR 2017 ...... 27

Figure 10. Performance against target for new enrollees by province, FY17 Q2 ...... 28

Figure 11. Number of children with advanced HIV infection newly enrolled on ART, by project over the life of the project ...... 30

Figure 12. Number of ADR notifications in comparison to quarterly target by province, FY17 Q2 ...... 37

Figure 13. PMTCT cascade, FY17 Q2 ...... 39

Figure 14. Option B+ coverage among HIV-positive pregnant women, by province and quarter ...... 41

Figure 15. Number of infants born to HIV-positive women who received an HIV test within 12 months of birth, FY17 Q2...... 43

Figure 16. TB cascade, FY17 Q2 ...... 44

Figure 17. TB patients registered, by province and quarter ...... 45

Figure 18. Percent of all newly diagnosed patients linked to care and treatment in select facilities in Chimoio City, by month, FY1 Q2 ...... 54

Figure 19. Number tested over time through C-HTC, by province and quarter, life of project ...... 59

Figure 20. Busca cascade per province, FY17 Q2 ...... 67

Figure 21. Map of EPTS sites by year of handover ...... 69

Figure 22. Site accessibility by support type, FY17 Q2 ...... 76

6 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

LIST OF TABLES Table 1. Performance on selected indicators at the end of FY17 Q2 ...... 12

Table 2. Testing results by sector in Q1 and Q2, 2017 ...... 17

Table 3. Yield and contribution to cases identified by modality, FY17 Q2 and S1 ...... 18

Table 4. Positivity in triage at Super 16 sites from January 2016 through March 2017 ...... 19

Table 5. Performance against target by province and testing modality, FY17 Q2 ...... 20

Table 6. Comparison of 12-month retention rates at SAPR 17 with and without conflict zones...... 24

Table 7. GAAC enrollment by province, FY17 Q2 ...... 25

Table 8. Comparison of percent of those enrolled in care who initiated in ART before and after T&S ...... 26

Table 9. Comparison of retention rates in T&S and non-T&S scale-up sites, APR16 and SAPR17 ...... 28

Table 10. Number of patients enrolled in three-month dispensing in CHASS-supported HFs ...... 36

Table 11. Performance of key PMTCT indicators by province, FY17 Q2 ...... 41

Table 12. Number of people treated for GBV services and services provided by province, FY17 Q2 ...... 49

Table 13. Proportion of VSL members who are PLHIV, by quarter, FY17 ...... 57

Table 14. Estimated coverage of index case testing by province, FY17 Q2 ...... 60

Table 15. Positivity rate in index case testing by group and province, FY17 Q2 ...... 61

Table 16. Referrals reported for HF services—referrals made and patient-referrals received, FY17 Q2 .... 65

Table 17. Results of busca consentida by group, FY17 Q2 ...... 66

Table 18. Funds disbursed to DPS, FY17 ...... 73

Table 19. Funds Disbursed with SDSMAS, FY17 ...... 74

Table 20. Funds Disbursed to CBOs, FY17 ...... 74

Table 21. Number of planned and completed TA visits by province and quarter, FY17 ...... 74

Table 22. Coverage of sites for data collection by province and support type, FY17 Q2 ...... 77

7 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

LIST OF ACRONYMS AND ABBREVIATIONS ADR Adverse Drug Reaction AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral CBO Community-Based Organization CCR Consulta da Criança em Risco (High-Risk Consultation for Children) CD4 Cluster of Differentiation 4 CDC U.S. Centers for Disease Control and Prevention CHAI Clinton Health Access Initiative CHASS Clinical and Community HIV/AIDS Services Strengthening C-HTC Community HIV Testing and Counseling CMAM Centro de Medicamentos e Artigos Medicos (Central medical stores), CS Centro de Saúde (Health Centre) DDM Direcção Distrital de Medicamentos (District Drug Directorate) DPM Direcção Provincial de Medicamentos (Provincial Drug Directorate) DPS Direcção Provincial da Saúde (Provincial Health Directorate) DSD Direct Service Delivery DVIT Data Verification and Improvement EID Early Infant Diagnosis EPTS Electronic Patient Tracking System FILA Ficha Individual de Levantamento de ARVs (individual patient drug pick-up records) FY Fiscal Year GAAC Grupo de Apoio e Adesão da Comunidade (Community Support and Adherence Group) HF Health Facility HIV Human Immunodeficiency Virus HRH Human Resources for Health HSS Health Systems Strengthening HTC HIV Testing and Counseling IR Intermediate Result LRDA Livro de registo de ARVs; daily antiretroviral register M&E Monitoring and Evaluation MCH Maternal and Child Health MISAU Ministerio da Saúde (Ministry of Health) MMIA antiretroviral (ARV) and RTK consumption data report forms (MMIAs) OVC Orphans and Vulnerable Children PCR Polymerase Chain Reaction PDSA Plan-Do-Study-Act PEPFAR U.S. President’s Emergency Plan for AIDS Relief PICT Provider-Initiated Counseling and Testing PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission POC Point-of-Care PPP Public-Private Partnership PS Posto de Saude (Health Post) 8 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

PSS Psychosocial Support PV Pharmacovigilance ROOT Routing Opt-Out Testing RTK Rapid Test Kit SCBA System Capacity Builder Approach SDSMAS Serviços Distritais de Saude, Mulheres Acão Social (District Directorate for Health, Women, and Social Action Services) SMS Short Message Service TA Technical Assistance TB Tuberculosis TSV Technical Support Visit UCSF University of California at San Francisco USAID U.S. Agency for International Development VCT Voluntary Counseling and Testing VSL Village Savings and Loan WHO World Health Organization

9 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

EXECUTIVE SUMMARY In this report, the Clinical and Community HIV/AIDS Services Strengthening (CHASS) project presents achievements for the second quarter of fiscal year (FY) 17. Overall, the results show strong and improving performance with increases in testing, particularly provider initiated counselling and testing (PICT) and rapid growth in the number of new patients enrolled in ART. That said, continued efforts are needed to improve retention in care and to address some specific groups, especially children and people co-infected with TB and HIV.

In the second quarter of FY 17, CHASS again surpassed its targets in terms of the number of individuals who received HIV testing and counseling (HTC) and received their test results by more than 10 percent, with 417,658 people tested across all sectors in CHASS-supported sites. Continued growth in testing is part of the strategy required to ensure that the ambitious targets for the number of new enrollees are achieved. Specific efforts included the introduction of CHASS-supported counselors at high volume and high positivity sites, expansion of PICT to new entry points in facilities, and the use of Plan-Do-See-Act (PDSA) cycles to improve coverage in priority sectors.

These efforts are being complemented by targeted efforts designed to ensure linkages to care and initiation on antiretroviral therapy (ART). In particular, patient flow was improved, escorts were provided, and psychosocial support was strengthened. With 29,171 people testing positive for HIV and 21,319 (73 percent) of them enrolled in care across the four provinces (Figure 1), the percent of patients linked to care increased by 5 percentage point increased (from 68 percent) despite the almost 30 percent increase in the number of newly diagnosed patients. With this size increase, it would have been easy to experience a drop in coverage if linkages had not been strengthened simultaneously. The number and percentage of patients newly initiating on ART also increased (23,039 or 79 percent of those newly diagnosed) even though implementation of Test and Start (T&S) at new sites was delayed until Q3; this implementation would have been expected to lead to an even larger increase as eligible patients in care initiated ART.

Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q2

This quarter also provided an opportunity to assess the implementation of T&S and the results are promising. First, the percent of pre-ART patients who enrolled on ART increased from 48 percent in the

10 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

period before T&S to 93 percent in the 7 months after T&S in the same sites. Likewise, the CD4 counts of patients initiating on ART in T&S sites increased since implementation began which supports that patients are initiating on ART earlier, with CD4 average at initiation increasing from 405 to 465.

Overall, retention in care was unchanged in comparison to APR16 although in Manica, where retention was particularly low at APR16, saw an increase of has not increased dramatically since APR16 except in Manica province where retention increased from 57 percent to 68 percent. While specific steps were taken in Manica because of its poor performance at APR, the other provinces focused efforts on the earlier stages of the care and treatment cascade and results were affected by a number of issues that are described in detail in the report including a rapid increase in the number of sites where retention was assessed which included a shift from urban areas and a change in the methodology in EPTS sites.

CHASS-supported sites showed good performance in terms of the percentage of HIV-positive pregnant women who received antiretroviral (ARV) drugs to reduce the risk of mother-to-child-transmission, with 98 percent of women receiving ARV drugs. The quarterly cascade for the prevention of mother-to-child transmission (PMTCT; Figure 2) showed improvement in testing of women registering for antenatal care (ANC) but highlighted the need to continue to reinforce the importance of testing all exposed infants.

Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q2

More details of CHASS’s performance toward targets are in Table 1, which summarizes performance for key indicators in the second quarter of FY17 for all CHASS provinces. Achievements in green reflect achievement at or above 85 percent of the quarterly target, while those in red reflect areas where CHASS achieved less than 85 percent of the quarterly target. For the majority for these key indicators, CHASS is on track to achieve the annual targets for 2017. Retention in care is the one indicator that requires particular improvement in order to achieve the target. Interventions to address this are described in the Care and Treatment section of the report. All of the results presented here are detailed in the following sections of the report, where performance is explained and actions needed are discussed.

11 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Table 1. Performance on selected indicators at the end of FY17 Q2 FY17 Q1 FY17 Q2 FY17 S1 Annual Quarterly % Quarterly % Cumulative Cumulative Indicator target performance achieved performance achieved performance % achieved % of adults and children who initiated ART 12-15 months prior to current reporting period who are alive and in care (SEMI- ANNUAL) CHASS 80% NA NA 67% Manica 80% NA NA 62% Niassa 80% NA NA 74% Sofala 80% NA NA 65% Tete 80% NA NA 76% # of individuals who received counseling and testing services for HIV and received their test results - all sectors CHASS 1,128,442 344,857 31% 417,658 37% 762,515 68% Manica 712,537 133,679 19% 171,644 24% 305,323 43% Niassa 43,270 45,995 106% 43,888 101% 89,883 208% Sofala 219,808 84,374 38% 102,136 46% 186,510 85% Tete 152,827 80,809 53% 99,990 65% 180,799 118% # of individuals with advanced HIV infection currently receiving ART - TOTAL CHASS 238,233 209,886 88% 217,807 91% 217,807 91% Manica 86,816 70,666 81% 77,875 90% 77,875 90% Niassa 11,614 19,411 167% 20,785 179% 20,785 179% Sofala 92,860 80,541 87% 82,601 89% 82,601 89% Tete 46,943 51,968 111% 52,273 111% 52,273 111% # of adults and children w/ advanced HIV infection newly enrolled on ART CHASS 79,277 18,154 23% 23,039 29% 41,193 52% Manica 35,392 6,325 18% 8,502 24% 14,827 42% Niassa 3,389 1,981 58% 1,872 55% 3,853 114% Sofala 29,697 6,216 21% 8,336 28% 14,552 49% Tete 10,799 3,632 34% 4,329 40% 7,961 74% % of pregnant women with known HIV status CHASS 99% 97% 98% 98% 99% 98% 99% Manica 99% 99% 100% 99% 100% 99% 100% Niassa 99% 101% 102% 94% 95% 94% 95% Sofala 99% 93% 94% 99% 100% 99% 100% Tete 99% 95% 96% 99% 100% 99% 100% % of HIV-positive pregnant women who received ARV drugs to reduce risk of mother-to-child-transmission CHASS 99% 97% 98% 98% 99% 98% 99% Manica 99% 97% 98% 99% 100% 99% 100% Niassa 99% 94% 95% 95% 96% 95% 96% Sofala 99% 98% 99% 98% 99% 98% 99% Tete 99% 97% 98% 99% 100% 99% 100% % of TB/HIV co-infected patients on ART (SEMI-ANNUAL) CHASS 100% NA 90% 90% 90% Manica 100% NA 92% 92% 92% Niassa 100% NA 88% 88% 88% Sofala 100% NA 90% 90% 90% Tete 100% NA 91% 91% 91%

With regard to priority interventions in Q2, a National Task Force worked in Manica and Sofala provinces as well as in Tete at the end of the quarter, to address key issues identified in Q1. The Task Force works with the provincial teams to identify potential solutions that can help to ensure quality of care and achieve project targets. The specific focus of the Task Force are described in the relevant sections of the report.

12 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

CHASS continued supporting the Ministerio da Saude (Ministry of Health) (MISAU) in rolling out Test and Start in all phase 1 sites in the four provinces, as well as implementing the differentiated care model in which stable patients 1) receive three-month ARV drug refills and 2) return for consultations every six months. CHASS zonal teams mentored health facility workers in participating sites in both initiatives to ensure awareness of, implementation of, and compliance with the respective national guidelines.

CHASS continued to expand the electronic patient tracking system (EPTS) this quarter, with five new sites with retrospective data entry completed, including Ponta Gea in Sofala, perhaps the biggest and most challenging site in the CHASS portfolio. Progress in EPTS expansion made it possible for CHASS to report from 35 EPTS sites this quarter, up from 24 at the end of FY16 and 30 at the end of Q1.

Because the ceasefire agreed to between RENAMO and the Government of Mozambique in late 2016 has been extended, CHASS was able to provide technical assistance and to collect data in all districts this quarter—the first time since the project was expanded to Manica, Sofala, and Tete. Some sites continue to be affected in that they were closed during the political turmoil. These sites are scheduled to re-open in Q3. Although political instability did not affect technical assistance or data collection in Q2, 28 sites were not accessible due to flooding from seasonal rains (Annex 1).

13 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

PROJECT OVERVIEW The Clinical and Community HIV/AIDS Services Strengthening (CHASS) project aims to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in the four provinces of Sofala, Manica, Tete, and Niassa by ensuring that the right HIV/AIDS interventions are implemented, at the right time and in the right places, so as to contribute to the desired goal of epidemic control in Mozambique. This eight-year, US$137,982,151 USAID-funded project began on August 1, 2010, and will end on July 31, 2018.

CHASS is pursuing five objectives:

1) Increase coverage of antiretroviral therapy (ART) to 90 percent. 2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively. 3) Increase the average cluster of differentiation 4 (CD4) count at initiation of ART from 350 to 500 cells per cubic millimeter. 4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB. 5) Operationalize viral load testing.

To achieve these objectives, CHASS combines technical capacity strengthening of health facilities (HFs) and community-based organizations (CBOs), direct support for quality and integrated HIV/AIDS service delivery, and health systems strengthening (HSS) at provincial, district, and HF levels. The project is implemented jointly with local organizations, district health teams, provincial health teams, and the Ministerio da Saúde (Ministry of Health) (MISAU). In support of the USAID Forward principles, CHASS emphasizes technical assistance (TA) to host government and local organizations to enhance local ownership of the national response.

In line with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 3.0, CHASS uses a data-driven approach that strategically targets geographic areas and populations to achieve the most impact for investments. This approach aims to close existing coverage gaps and increase access by saturating services in districts and communities where HIV prevalence and unmet need are high. To this end, CHASS provides differentiated packages of support (i.e., scale-up, sustained transition/central support) to HFs and prioritizes scale-up in districts and HFs that have the highest HIV burden, with the goal of reaching saturation levels (Figure 3). In total, CHASS supports 346 ART sites, 379 prevention of mother-to-child transmission (PMTCT) sites, and 388 HIV testing and counselling (HTC) sites in 56 districts.1

CHASS has three intermediate results (IRs):

 IR1: Strengthened facility-based HIV services.  IR2: Strengthened community-based HIV services.  IR3: Strengthened referral and linkage systems between community and facility-based HIV services.

1 These sites do not include PMTCT sites, all of which do HTC within PMTCT. They include sites that provide either voluntary counseling and testing or provider-initiated testing and counseling. 14 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and facilities providing ART services, FY17 Q2

The next sections of the report highlight accomplishments by IR, in specific program/technical areas from January to March 2017. The sections state how, in the past quarter, CHASS worked with direcçãos provincial da Saúde (provincial health directorates) (DPSs) and with serviços distritais de saude, mulheres acão social (district directorates for health, women, and social action services) (SDSMASs) to address obstacles affecting access to and quality of facility-based HIV/AIDS services in the four provinces.

15 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA

IR1: STRENGTHEN FACILITY-BASED HIV SERVICES

The ultimate goal of CHASS activities is to enable HFs to scale up the provision of integrated health and HIV/AIDS services and meet the standards specified by MISAU and other world bodies such as the World Health Organization (WHO). To achieve this, the project supports interventions in a wide range of areas including improving the knowledge and skills of health workers, enhancing the capacities of provincial and district health personnel to effectively supervise and manage HFs, activating more sites for HIV/AIDS services so as to enhance access, improving documentation and reporting at the HF level, and improving supply chain and logistics management to enhance the security of health commodities. Strengthening facility-based services also entails improving linkages and referrals both within the HFs and between HFs and CBOs or other service providers so as to ensure a continuum of care for PLHIV.

HIV Testing and Counseling The goal of CHASS HTC activities is to ensure that 90 percent of people with HIV in CHASS provinces are diagnosed. This is being pursued by emphasizing HTC for populations and locations that are likely to yield high rates of HIV positivity. The project continues to support multiple approaches including routine opt- out testing (ROOT), provider-initiated counseling and testing (PICT), stand-alone voluntary counseling and testing (VCT), and community HIV testing and counseling (C-HTC) that emphasizes index case testing. In fiscal year (FY) 17, the target is to offer HTC to 1,517,184 individuals. To achieve the ambitious FY17 HTC target, CHASS emphasizes:

 Prioritizing interventions in population groups likely to yield high rates of HIV positivity (e.g., index case testing, optimizing PICT in high-yield sectors), and focusing on the “right” geographic areas (i.e., high prevalence districts and sites where directly observed therapy for TB is provided).  Organizing patients flow and improving documentation (e.g., HTC registers) in all HTC sites so as to reduce missed opportunities and enhance data capture.  Conducting systematic PICT trainings of health care providers at all entry points in the 16 priority sites and high-volume HFs  Deploying counselors in high-volume HFs to improve pre- and post-test counseling as well as adherence counseling and support.

Performance in counseling and testing

In the second quarter of FY17, CHASS tested 417,658 people for HIV and identified 29,171 (7.0 percent) as HIV-positive. This represents a 19 percent increase in the number of people tested (from 351,873 in Q1) and a 27 percent increase in the number of people identified as HIV-positive (from 22,926). This increase was the result of a quality improvement (QI) initiative CHASS undertook in Manica and Sofala. Beginning in Sofala in Q1 and expanded to Manica in Q2, CHASS has organized workshops on PICT for staff from priority facilities to discuss performance and agree upon coverage targets for testing among patients who attend consultations or screenings. These initial workshops were followed by monthly meetings to evaluate the implementation and share lessons learned; the meetings included data review,

16 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

experience sharing, and recognition of high-performing providers (i.e., those reporting high volume and high positivity). To improve performance, ROOT for children was implemented at some facilities in order to increase the number of HIV-positive children identified. Notably, of the six facilities that participated in the first workshop in December, four increased the number of people tested in PICT by more than 50 percent, and two of those by over 200 percent, relative to Q1.

In some cases, the addition of CHASS counsellors also contributed to gains in the number of people tested. Counselors were added in 21 VCT units across Manica, Sofala, and Tete. In these sites, the number of people tested in VCT increased by 23 percent relative to Q1, whereas in sites where no counsellors were added, the number of people tested increased by just 3 percent. Some sites showed massive increases. For example, Caminhos de ferro de Moçambique Health Center and Moatize Health Center in Moatize District in Tete both benefited from the addition of a CHASS counsellor with more than a doubling of the number of people tested. Likewise, in the 23 sites where CHASS introduced PICT counsellors, the number of people tested increased by 97 percent compared with Q1, versus a 24- percent increase in sites without additional counsellors. In this case, we could not tease out the independent effect of these counsellors, as all but one of the sites with new PICT counselors in Manica and Sofala also participated in the PICT QI effort.

The specific impact of these initiatives was seen in the 36 percent increase in numbers tested via PICT and the 9 percent increase in the number tested via VCT (Table 2). Other sectors without these initiatives saw much smaller growth (less than 5 percent in antenatal care [ANC], maternity, and consulta da criança em risco [high-risk consultation for children) [CCR]). The number of patients tested through community VCT and in the TB sector declined relative to last quarter. These declines are discussed in the relevant sections of the report.

Table 2. Testing results by sector in Q1 and Q2, 2017 Sector Quarter 1 Quarter 2 % change Q1-Q2 # tested % positive # positive # tested % positive # positive # tested VCT 40,910 13% 5,144 44,652 12% 5,422 9% PICT 175,603 6% 9,972 239,087 7% 16,143 36% C-HTC 21,764 14% 3,095 15,341 17% 2,597 -30% Case Index 6,813 23% 1,566 Other C-HTC 8,528 12% 1,031 ANC 91,907 4% 3,829 96,903 4% 4,209 5% Maternity 12,644 1% 124 13,041 1% 120 3% CCR (<12 months) 5,668 5% 267 5,760 5% 278 2% TB 3,377 15% 495 2,874 14% 402 -17% Total 351,873 7% 22,926 419,136 7% 28,606 19%

The number of people tested increased this quarter, resulting in more people being identified HIV- positive and subsequently enrolled in ART services (see Care and Treatment, below). However, improving testing yield is a priority for CHASS. In Q2, as in Q1, 7 percent of all people tested were HIV-positive. As in the past, the percent positive varied widely by sector (Figure 4), from a high of 14 percent among those newly tested in the TB sector to a low of less than 1 percent in maternity. These positivity rates were consistent with performance last quarter, although positivity in C-HTC was slightly lower this quarter. This was due in part to the improvement in data quality that resulted from CHASS monitoring and evaluation (M&E) teams working with CBOs to review and revise their data prior to reporting, as well as to the initiation of monthly data review meetings with community partners. 17 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

In terms of the three main modalities of testing, yield was greatest in C-HTC index case testing, but fewer people were identified through C-HTC because the number of people tested was relatively small (Table 3). Given the intensive nature of C-HTC, this is not likely to change, but CBOs will be encouraged to continue to focus more on index case testing, where yield is highest.

Table 3. Yield and contribution to cases identified by modality, FY17 Q2 and S1 Q2 S1 (Q1 + Q2) % of positives % of positives Modality Yield (% Yield (% identified via # tested identified via # tested positive) positive) this modality this modality VCT 12% 22% 44,652 12% 22% 85,562 PICT 7% 67% 239,087 6% 55% 414,690 CI C-HTC 23% 6% 6,813 24% 6% 12,435 Other C-HTC 12% 4% 8,528 23% 4% 17,654

Figure 4. HIV positivity yield by sector and quarter, over the past year

The lack of change with regard to positivity rates is expected given that the initiative undertaken to improve testing was focused on increasing coverage and not yield. Data from the triage units in 16 priority sites under CHASS reflect this (Table 4), with almost all sites outside of Tete showing a substantial increase in the number of patients tested in the triage unit and seven of the sites posting lower positivity this quarter than last. Other sectors did not have sufficient data over time from enough of these sites to allow for this type of analysis.

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Table 4. Positivity in triage at Super 16 sites from January 2016 through March 2017 # Tested % Positive Health Facility Jul to Oct to Jan to Jul to Oct to Jan to Sept 2016 Dec 2016 Mar 2017 Sept 2016 Dec 2016 Mar 2017 Manica / Cidade de Chimoio / 1 º de Maio NA 4624 5828 NA 3% 6% Manica / Cidade de Chimoio / 7 de Abril NA 506 4889 NA 2% 7% Manica / Cidade de Chimoio / Eduardo Mondlane 186 708 1206 15% 20% 22% Niassa / Cidade de Lichinga / Centee de Saude Chiuaula 51 418 1111 4% 14% 9% Niassa / Cidade de Lichinga / Centee de Saude Lichinga 83 291 1237 27% 8% 10% Sofala / Cidade da Beira / Beira Hospital Central 795 349 352 6% 3% 6% Sofala / Cidade da Beira / Macurungo 63 161 416 44% 6% 6% Sofala / Cidade da Beira / Manga Mascarenha 136 141 280 17% 35% 40% Sofala / Cidade da Beira / Manga Nhaconjo 113 139 355 15% 6% 19% Sofala / Cidade da Beira / Munhava 157 257 73 14% 10% 7% Sofala / Cidade da Beira / Ponta Gea 55 178 321 18% 21% 21% Tete / Cidade de Tete / Nº 1 - Bairro Magaia 304 81 35 3% 7% 3% Tete / Cidade de Tete / Nº 3 - Bairro Manyanga 546 67 20 2% 18% 30% Tete / Cidade de Tete / Nº 4 - Bairro Muthemba 876 30 71 4% 13% 15%

Given the aim of optimizing PICT, CHASS continues to analyze available data to identify sectors with higher yield. However, due to the small number of sites with more than one quarter of data for specific sectors, this analysis is limited at this time. The results from triage, which were available for a sufficient number of sites, showed that yield was higher than the overall yield for PICT, at about 10 percent. In Q3, specific initiatives to be carried out include expanding the successful approaches implemented in Q2 in Manica and Sofala (described above) to additional large-volume and high-positivity sites not yet implementing them. CHASS will also revise its data collection tools for manual sites to collect more detailed data within these broad sectors. For example, data on Banco de Socorros will be collected separately from triage, where it is included at this time.

Variation by geographic area

CHASS has conducted a district-level and site-level analysis of HTC data that is not presented here. These results are being used to identify high- and low-performing areas in order to target TA in Q3, and are available on request.

Performance against HTC targets

CHASS was on or above target for HTC overall, surpassing the targets in PICT and ANC, meeting the targets for CCR and C-HTC, and not reaching the targets for TB, maternity, and VCT (Figure 5). Given that the PEPFAR targets are based on modeling of the number of people who are anticipated to be HIV- positive and the number who do not yet know their status, overall these results suggest that CHASS is testing a sufficient number of people to ensure that 90 percent of PLHIV know their status. In the sectors showing underperformance, the number of patients tested is not directly under the influence of the project. For example, in TB services, the number of people tested depends on two key factors: 1) the number of patients registered in the TB sector and the number of people who already know their HIV- positive status when they are registered. In Q2, CHASS did not meet the targets for the number of people tested in the TB sector, both because the number of people registered was below target (see TB below) and because 50 percent of patients knew their status at entry, leaving relatively little room for new tests. In fact, 98 percent of all patients who did not know their status at entry were tested. The number of 19 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

patients tested in maternity is dependent on the number of women who deliver in facilities and the percent of these women who do not know their status. In fact, very few women need testing in the maternity. Finally, because VCT is a voluntary service, the main way to increase the number of people tested in the VCT units is through demand creation. One means to do this is through passive referrals of partners of people diagnosed as HIV-positive—something CHASS is already doing. As we develop systems to measure the number of people tested through facility-based index case testing, we will be able to track improvements in this regard. CHASS is also implementing a range of demand creation strategies in communities including radio programs, dialogues, theater, films/discussion, and health education sessions in various sites including within village savings and loan (VSL) clubs. In Sofala, the Clarisse Campaign is an additional demand creation activity receiving CHASS support.

Figure 5. Performance against target in HTC, by sector, FY17 Q2

Abbreviations: ANC, antenatal care; CCR, consulta da criança em risco (high-risk consultation for children)

At the provincial level, Niassa is the best performer relative to HTC targets, being above or on target for all HTC modalities (Table 5). Sofala, on the other hand, was below target for all modalities except PICT and ANC, where it was above target. In part this may be due to the intense focus on PICT in Sofala this quarter which may have diverted attention from VCT. In maternity and CCR this is more likely the result of issues with the targets. In addition to variation across provinces, performance also varied by modality. For example, although CHASS was below target for VCT, it was above target in Niassa and on target in Tete.

Table 5. Performance against target by province and testing modality, FY17 Q2 Province VCT PICT C-HTC ANC Maternity CCR TB* CHASS 80% 134% 91% 117% 67% 88% 143% Manica 64% 109% 39% 109% 45% 95% 104% Niassa 173% 218% 329% 151% 160% 165% 193% Sofala 79% 154% 85% 116% 70% 74% 138% Tete 111% 173% 202% 111% 76% 81% 234% * The targets for newly tested individuals in the TB sector underestimate the number of people who require a test. For example, in direct service delivery (DSD) sites, only 28 percent of all patients with a result in the register were targeted for a new test, whereas our data suggest that about half of all new TB patients will not know their status.

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Challenges related to HTC

 As community counselors transitioned to using two separate registers, not all counselors were vigilant about proper recording, leading to some misclassification of people tested. Although CHASS has been addressing this through mentoring, this may have affected data, particularly early in Q2.

Key HTC activities for the next quarter

 As part of the continuation of its work with the facilities that participated in the QI initiative in Q1 and Q2, CHASS will transition providers in these sites to a more focused approach to PICT, providing guidance on implementation of the testing algorithm and ensuring quality of testing.

Care and Treatment In Q2, CHASS supported the DPS and SDSMAS in preparation for Phase II of T&S. CHASS worked with the DPS to conduct readiness assessments for the 54 sites that will start to implement this strategy in early April, supported training for clinical staff and disseminating job aids.

The CHASS National Task Force focused on practices designed to increase enrollment on ART. At priority sites, they introduced performance monitoring spreadsheets to track new diagnoses and the number of new enrollees, linkages to care, and community activities (e.g., household visits for new patients and busca consentida).2 CHASS then worked with sites to use these daily data to evaluate their performance on an ongoing basis in order to provide feedback to clinical staff. An informal system for tracking newly diagnosed patients was also introduced in select sites to encourage providers to follow patients through to care and treatment. CHASS continued to work with sites to review clinical charts in order to identify and enroll patients who are eligible for ART but have not yet started. CHASS provided on-the-job training during TA visits about the advantages of using clinical criteria for initiating ART when CD4 results are not available. In sites with point of care CD4 (Pima™), CHASS mentored providers on the need to prioritize CD4 testing for patients who have been newly diagnosed with HIV.

CHASS also continued to expand the differentiated care model, which provides a variety of options to patients on care and treatment in order to facilitate retention and adherence. Key options include grupos de apoio e adesão da comunidade (community support and adherence groups) (GAACs); three-month drug pick-up; and rapid flow, which enables patients to obtain a prescription for six months of medication but requires monthly pick-up of the drugs. These different options are provided based on risk of dropout as well as patient preferences.

As described in the HSS section of the report, CHASS is also working with sites to improve patient flow in order to reduce waiting times and improve patient’s experience of care.

Finally, CHASS is continuing to support the expansion of viral load testing as discussed in the section on Laboratory, working with clinicians to ensure routine testing for eligible patients as well as testing for

2 These daily monitoring spreadsheets are currently being converted to an electronic tool to aid in review and aggregation of these data and to facilitate support from a distance. The application is currently being tested. 21 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

patients with suspected treatment failure. CHASS is working to ensure that clinicians obtain these test results and use them for clinical decision making.

Performance in care and treatment

Overall, performance across the ART cascade was strong this 1,724 children under age 15 were quarter. Out of 29,171 people who tested positive for HIV, enrolled on ART in Q2. This is 7% of all 23,039 (79 percent) enrolled in ART across the four provinces new enrollees. (Figure 6)—a 27 percent increase from the 18,154 enrolled in Q1, the largest number reported in any quarter to date, and 15,011 females were enrolled. This was almost double the number newly enrolled in the same 65% of all new enrollees. quarter last year (Figure 7). This increase was the result of efforts both to identify more people who were HIV-positive and did not know their status and to link those patients who tested positive to care. Specific activities to improve testing are described in the Testing and Counseling section of the report.

Figure 6. ART cascade, FY17 Q2

With regard to linkage to care, in Q2, CHASS continued to support patient escorts between testing units and care and treatment; worked to improve patient flow with the HF from the testing unit where the chart is opened to psychosocial support, to care and treatment; and worked with HFs to prioritize newly diagnosed patients in order to decrease their waiting time and ensure that they had a consultation on the same day as diagnosis. The addition of CHASS counselors also supports this in that these counselors are trained to open the clinical chart at the time of diagnosis.

In Q2, 21,319 patients were enrolled in care across CHASS-supported sites—73 percent of all newly diagnosed patients. The higher number of patients enrolled on ART than in care is a trend seen over time and is the result of patients enrolling in care and in treatment in different quarters, particularly with initiatives to enroll patients who are eligible but not yet enrolled. It may also reflect some underreporting of patients enrolled in care. 22 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

The effect of these activities was seen in the maintenance of the high percentage of newly diagnosed patients who initiated on ART, despite a large increase in the number of people diagnosed. As noted in past reports, the level of coverage seen this year was far superior to the less than 50 percent seen in the first half of FY16. When coverage is high, improvements are likely to be smaller, as there is less room for improvement overall. That said, CHASS will continue to focus on ensuring that all newly diagnosed patients are started on treatment in Q3 in order to further close this gap. The implementation of Test and Start at Phase II sites should also contribute to closing this gap.

Figure 7. Number of patients newly enrolled in ART by quarter and province, FY17

Overall, CHASS showed the same level of 12-month Cultural and Religious Influences on retention this quarter as at APR16. However, the sites Retention in Manica included at APR16 were fewer and were focused on large urban areas, whereas the SAPR17 data include CHASS staff in Manica reported that almost all CHASS-supported sites, including those in some PLHIV requested re-testing on conflict-affected zones. Furthermore, 12-month Mondays after having participated in retention in Manica province increased from 57 to 62 religious ceremonies alleged to cure percent (Figure 8). The CHASS National Task Force and AIDS. On further investigation, they the Manica team prioritized retention based on the low discovered that some churches are level of retention at APR16 and the generally low level of requiring PLHIV to publicly burn their retention in Manica over time. A key activity was antiretroviral (ARVs) drugs as a triangulation of data—reviewing again the data in the demonstration of faith in miracle water electronic patient tracking system (EPTS), the clinical that they must purchase. See IR2 for chart, and the pharmacy to ensure that outcomes of all more detail. patients were accurately recorded. As discussed in past reports, ensuring that the EPTS and chart are updated based on the ficha individual de levantamento de ARV drugs (FILA or individual patient drug pick-up record) remains a challenge. However, this is being addressed through a pharmacy intervention (see Pharmacy section of this report), through increased focus on this issue on the part of the clinical team, and through the reorganization of the ficheiro móvel. A more concerted effort was made to review the list 23 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

of abandoned patients generated from the EPTS to ensure that patients who were listed for busca consentida were actually late for a drug pick-up or consultation. This increased the efficiency of the busca consentida process. CHASS is also working at site level to better ensure that the results of busca consentida are updated in the EPTS.

Figure 8. 12-month retention rates at SAPR 17, by province

The ability to access a larger percentage of sites this quarter affected the retention rate in Manica because some districts that were not accessible due to political conflict have lower retention rates. In sites where retention was measured in APR16 and SAPR17, the retention rate increased from 57 percent to 68 percent. When all sites were included, the retention rate for the province was just 62 percent because of the lower retention rates in the former conflict districts. For example, the 12-month retention rate in Barue District of Manica was just 43 percent, and that in Mossurize was just 48 percent (substantially below the rest of Manica). The addition of conflict districts to CHASS retention measures did not have an effect in the other provinces (Table 6). Although Sofala appeared to have lower retention when the conflict zones were excluded (the reverse of what we expected), this was not a significant difference (p= 0.22).

Table 6. Comparison of 12-month retention rates at SAPR 17 with and without conflict zones Sites reported All sites in APR16 Manica 62% 68% Niassa 74% 74% Sofala 65% 64% Tete 76% 76% All 67% 69%

Another challenge in comparing APR16 and SAPR17 data was that the methodology used for EPTS sites changed this quarter. We ran the retention data at EPTS sites using both the old and the new queries to understand the potential impact on retention rates. There were small differences (less than 1 percent) at some sites, as expected, but one site had a difference of more than 30 percent, which we are exploring.

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Taking into account both new enrollees and patients who were lost to follow-up or exited care for other reasons (e.g., transfers, deaths, suspension of treatment), a total of 233,534 patients were active on ART at the end of Q2—an increase of 5 percent from the 222,586 enrolled at the end of Q1. This reflects a loss of 2,612 patients (1.2 percent) who were recorded as active on ART in Q1 but who were found, during the process of data review and cleaning for EPTS implementation, to be duplicate patients or to have incorrect information in the paper records. Thus, the true growth in ART patients was actually more than 6 percent.

Grupos de apoio e adesão da comunidade. In all provinces, the number of sites with grupos de apoio e adesão da comunidade (community support and adherence groups) (GAACs) and the number of members increased (Table 7). In Manica, GAACs were expanded to two additional sites in Q2, and the number of members increased from 3,709 to 3,929. Niassa added 35 additional groups and 79 members; this reduced the average size of GAACs in the province by almost one person. In the sites in Sofala with GAACs, 173 new groups were formed, with a total of 531 patients added to GAACs. In Tete, where GAACs have been more widely implemented to date, four more sites added GAACs, but only 48 patients were added; the provincial team believes that the number of patients in GAACs may be declining with the transition to three-month drug pick-up. With differentiated models of care, patients have greater options to manage their treatment. The average number of members per group remained below the guidance at 2.8 (ranging from 2.6 in Tete to 3.6 in Niassa). However, given the effectiveness of GAACs, even when members are below the suggested number per group, these groups remain a priority intervention for CHASS. Data from our manual data continue to support the effectiveness of GAACs, with 6-month retention of 88 percent compared with 79 percent among non-GACC members and 12-month retention of 83 percent compared with 62 percent among non-GAAC members. This crude analysis did not control for other factors that may have influenced outcomes, such as province and age and sex of the cohort members.

Table 7. GAAC enrollment by province, FY17 Q2 Province # of Members Groups Average facilities size Manica 53 3,929 1,132 3.5 Niassa 8 347 96 3.6 Sofala 43 5,370 1,893 2.8 Tete 69 12,320 4,657 2.6 TOTAL 173 21,966 7,778 2.8

Viral load. Preliminary data on viral load testing were shared with USAID in the quarterly performance review presentation. The viral load data are still under review and will be shared shortly.

Variation by geographic area and interventions

An analysis of the care and treatment cascade per province shows that Niassa had the biggest gaps in enrollment in care and in treatment, with just 53 percent of all newly positive patients enrolled in care and 65 percent starting ART. In the other provinces, enrollment was 75 percent or more and the percent initiating on ART was at least 79 percent. Provincial-level cascades are presented in Annex 2.

With the advent of T&S in some areas, CHASS is also reviewing performance in these sites. A key aim of T&S is to immediately start all newly diagnosed patients in care and then to start them on ART within the

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first 15 days after diagnosis. A crude analysis of the T&S sites shows that the percent of pre-ART patients enrolled on ART has, in fact improved (Table 8). At the project level, the percent of pre-ART patients who enrolled on ART increased from 48 percent in the period before T&S to 93 percent in the 7 months after T&S. Female patients enrolled in ART were more likely to have initiated on ART (94 percent vs 91 percent, p<0.05) although this is likely biased by the approach in PMTCT in which all women are immediately initiated on ART. Likewise, children were somewhat more likely to enroll on ART (94 percent vs 93 percent, p<0.05). Both Sofala and Tete show more room for improvement than do Manica and Niassa where 97 percent of patients starting on pre-ART have already initiated ART. We do not expect this to reach 100 percent because some patients enroll too late in the quarter to have completed the period for enrollment and some may refuse to start ART.

Table 8. Comparison of percent of those enrolled in care who initiated in ART before and after T&S Province 7 months before T&S 7 months after T&S # enrolled in # initiating ARRT % initiating ART # enrolled # initiating ARRT % initiating ART care in care Manica 1,374 827 60% 5,168 5,008 97% Niassa 492 254 52% 1,201 1,162 97% Sofala 3,208 1,222 38% 4,776 4,168 87% Tete 900 580 64% 3,076 2,893 94% Total 5,974 2,883 48% 14,221 13,231 93%

To confirm that patients are enrolled earlier with the implementation of T&S, we compared average CD4 counts at T&S sites before and after T&S began. This analysis showed that CD4 counts were significantly higher following the implementation of T&S. The average CD4 count among the 9,100 patients with a CD4 count available in the seven months before the intervention started was 405, whereas in the seven months after T&S, the average CD4 count among the 6,682 patients enrolled at these same sites was 465 (p<0.05). This same trend was seen in all four provinces as well as by gender. Notably, a bigger difference was seen for men, with the average CD4 count increasing from 346 to 421 (a difference of 76); in women, it increased from 439 to 492 (a difference of 52).

Retention also varied by province, as in the past, ranging from 62 percent in Manica to 76 percent in Tete. Approaches that are being implemented to address retention in Manica are described above. CHASS also compared district level retention at SAPR to that at APR16 (Figure 9). In all three districts in Manica where retention was measured in both rounds, retention increased by more than 11 percentage points. The variability from period to period in some districts, apparent in the maps, was the result of the small number of people included in the cohorts. For example, Majune District in Niassa had just 20 people in the APR cohort and 15 in the SAPR cohort, so the outcome of one or two people could have had a large effect on the district retention rate. That said, half of the 36 districts that had data in both periods saw a decline in retention, and half saw an increase. Most importantly, some key scale-up districts (i.e., Cuamba, Beira City, Tete City) saw declines that require follow-up. These results will be used to determine focal districts for support in Q3.

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Figure 9. Twelve-month retention rates by district, APR16 and SAPR 2017

APR16

CHASS also compared retention at T&S sites with that at other sites in scale-up districts (Table 9) in order to identify any potential effect of this new approach on retention. Patients who enrolled under T&S at Phase I sites were not included in the cohort analyzed this quarter because the eligibility period for entry into this 12-month cohort ended prior to the initiation of T&S. However, this analysis was undertaken to explore the potential effect of T&S on the broader population of patients who may be affected as providers focus efforts on new enrollees. In fact, in Q2, with the exception of Manica, 12-month retention was lower in T&S sites on the whole than it was in non-T&S scale-up sites. The picture was more mixed at APR16, with the aggregate rate for T&S sites higher in both Tete and Manica than in non-T&S scale-up sites in the same provinces. In fact, retention rates did fall in the aggregate measures of 12-month retention among T&S sites at the provincial level in all provinces other than Manica, where substantial efforts were undertaken to address the retention rate as discussed above.

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Table 9. Comparison of retention rates in T&S and non-T&S scale-up sites, APR16 and SAPR17 APR 16 SAPR 17 Non-T&S Non-T&S Province T&S Scale-up T&S Scale-up Manica 55% 52% 77%↑ 57%↑ Niassa 70% 88% 67%↓ 73%↓ Sofala 63% 65% 60%↓ 69%↑ Tete 79% 74% 73%↓ 78%↑ All 64% 63% 68%↑ 67%↑

Performance against care and treatment targets

CHASS was on target for new enrollees in ART in Q2 (Figure 10), showing a 20 percentage point improvement in both DSD and TA sites. However, only 62 percent of the target for pediatric enrollments was achieved (see Pediatrics for further discussion). At the provincial level, all four provinces were at or above target for new enrollees. This level of achievement following a substantial increase in the targets for FY 2017 showed the impact of the targeted efforts that CHASS has undertaken to increase enrollments in care through both increased testing and improved linkages to care.

Figure 10. Performance against target for new enrollees by province, FY17 Q2

In terms of performance against target for the number of patients currently on ART, CHASS was below target in DSD sites but achieved 91 percent of the target in TA sites. This was due to the rapid escalation of targets in DSD sites from FY16 to FY17 and likely to some misallocation of targets by support type. Although we would not expect to achieve the annual target for this cumulative indicator in Q2, additional gains are needed in both enrollment and retention in order to achieve the FY17 targets.

Challenges related to care and treatment

 Implementation of Phase II of T&S was scheduled to begin in February 2017 but was delayed to mid-April to ensure that the results of the evaluation of Phase I and any resulting recommendations could be incorporated at Phase II sites.  With the further implementation of T&S at Phase I sites, CHASS is closely following retention at these sites to identify and address concerns. Preliminary monthly data (not presented here) suggest that retention among new enrollees at T&S sites is low.

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 Retention among pregnant women is a particular challenge as shown in the lower retention among this group.

Key care and treatment activities in the next quarter

 Support the rollout of T&S in the 11 new sites in Phase II, building on lessons learned in Phase I.  Work with psychosocial support focal points to identify patients who default or abandon care in the first six months of treatment to provide follow-up and additional adherence counseling.  Introduce additional counselors (e.g., Gestores de Casos and Mentor Mothers) to expand the availability of adherence counseling and reduce waiting time for this service.  As discussed in the PMTCT section of the report, strengthen male involvement as a means to improving retention of pregnant women. Ensure that the Ficheiro Movel is functional in PMTCT services.  Although data on Viral Load testing are not presented in this report as we continue to work on ensuring the quality of these data, CHASS will work to strengthen operationalization of viral load testing by ensuring that clinical staff request it for all eligible patients.

Pediatric Antiretroviral Therapy The CHASS pediatric treatment activities aim to improve case identification, treatment, and retention of HIV-positive children in care and treatment. CHASS uses a three-pronged strategic approach to achieve the above objectives: 1) identification of HIV-infected children/adolescents, 2) linkage of confirmed HIV- infected children/adolescents to ART clinics, and 3) initiation and retention in ART. To identify 90 percent of all HIV-positive children in the catchment areas of supported HFs, CHASS uses the See, Ask, and Test strategy in which each pediatric encounter—whether in HFs (in all sectors where children are seen) or through outreach activities (e.g., outreach immunization)—is an opportunity to screen for HIV exposure and infection.

During Q2, CHASS technical teams continued to perform pediatric treatment-related cascade analyses from diagnosis to treatment and retention, to identify leakages and develop interventions to efficiently address them. Key interventions implemented this quarter included:

 ROOT implementation at a group of priority sites including Munhava in Sofala and all facilities in Chimoio City.  Supporting the installation of point-of-care (POC) early infant diagnosis (EID) in Sofala in order to reduce the turn-around time.  Deploying additional staff at consultation, triage units, CCR, and wards in priority HFs to reinforce the See, Ask, and Test strategy and escort HIV-positive pediatric clients between HTC and care units.  Training HF staff in presumptive diagnosis  Ensuring initiation of HIV-positive children on ART within 15 days from the day the HIV diagnosis is known.  Mentoring HF workers on opening clinical records at the point of HIV testing.  Daily monitoring of HIV-positive cases and ensuring that they are linked to ART units for initiation, especially in high-volume HFs. 29 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

This quarter, synergies between CHASS and COVida were solidified at sites in districts where both projects work, with the strongest synergies formed in Tete. This should aid in the diagnosis of children who are HIV-positive, as COVida is referring children for testing (through both C-HTC and facility-based services) who might otherwise not be tested. We are working to document the number of children identified as HIV-positive through these referrals, at least in a sample of sites. In addition, CHASS is referring children to COVida, and this should help to improve retention and adherence, as COVida provides both adherence counseling and general support for families.

Performance in pediatric care and treatment

Achieving pediatric targets requires testing infants in the first year (see PMTCT) as well as testing young children and adolescents. The percentage of people tested who were children varied by sector, with 28 percent of those tested in C-HTC, 32 percent of those tested in PICT, and 9 percent of those tested in VCT being under the age of 15 years. For both VCT and C-HTC, the percentage was identical to Q1, but the percentage of children in PICT increased from 25 to 32 percent. This was likely the result of two initiatives: 1) the initiative to increase coverage of PICT described in the HTC section and 2) the implementation of ROOT for all children under 15. ROOT was implemented at a group of priority sites including Munhava in Sofala and all facilities in Chimoio City. It was also implemented in Tete City, although implementation began there in the last two weeks of the quarter and did not likely have a substantial effect on results.

In terms of new enrollees, CHASS saw a bigger increase in Q2 than in any quarter in the past year (Figure 11), with almost 70 percent more children enrolled than at the same time last year. This was the result of improved testing coverage of children as well as improved linkages to care.

Figure 11. Number of children with advanced HIV infection newly enrolled on ART, by project over the life of the project

Pediatric retention overall was 62 percent, and it was generally slightly lower than adult retention. This was related to the fact that a greater percentage of children than adults in the cohort had died (5 percent versus 2 percent). In Q3, CHASS will reinforce the quality of clinical follow-up (e.g., viral load testing, growth monitoring) to improve retention in children.

30 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Variation by geographic area and Intervention

The number of children tested in PICT increased most in Manica and Sofala, both of which saw a 70 percent increase, due to focused efforts to improve coverage. The biggest gains in new children initiating in ART were seen in Manica (a 44 percent increase) and Sofala (a 31 percent increase), highlighting the effect of these efforts to improve testing and linkages to care.

Assessing the direct effects of these interventions is challenging because 1) pediatric testing coverage prior to implementation is not known, 2) the interventions overlapped in some sites, and 3) increased access to facilities where the cease fire is in effect may have increased testing in those sites. That said, the available data support the effectiveness of these efforts. Substantial gains in the number of children tested were seen in all of the sites where ROOT was implemented in Manica and Sofala, with increases ranging from 70 percent to more than 300 percent. Furthermore, at the 114 sites where age- disaggregated data on testing results were collected, the number of HIV-positive children identified in PICT increased from 450 to 851 between Q1 and Q2. Not all sites where CHASS interventions to improve testing (PICT or ROOT) were implemented had disaggregated data; therefore, these results are only indicative but do suggest that increases in testing are largely responsible for the increased number of children initiating on ART this quarter. Moving forward, CHASS will continue to track these data in sites where disaggregated data are collected.

With regard to retention, in most provinces there appeared to be a small gap between adult and pediatric retention (difference of 2-4 percentage points), although these differences were not statistically significant at the provincial level. However, in Manica there was a 9 percentage point difference (p=0.002), highlighting the need for specific interventions aimed at children there.

Data from the COVida project suggest that synergies with CHASS are helping to ensure that families of orphans and vulnerable children (OVC) are referred to the project, which, as noted above, should help to improve retention and adherence among children and their parents. In CHASS districts where both CHASS and COVida work, 24 percent of all referrals came from HFs; in contrast, in districts where CHASS does not work, only 3 percent of referrals came from HFs. There were also more than six times as many referrals in the 10 synergies districts than there were in the 21 districts in other provinces.

Performance against pediatric care and treatment targets

CHASS remained below target for children initiating on ART but saw substantial improvement in all provinces in both DSD and TA sites. In general, enrolling new children on ART has been a challenge both because children living with HIV are not tested and because some are not enrolled in care. Relatively high death rates among the 12-month pediatric cohort support the belief that children who are not identified as HIV-positive when they are infants may have high mortality rates. Last quarter, project-wide performance was 49 percent of the target in DSD sites and 51 percent in TA sites, whereas this quarter it was 62 percent of the target in DSD sites and 66 percent in TA sites. To continue to improve performance, ROOT will be expanded to additional sites, PICT will be expanded to more entry points at facilities where this has not yet been done, and clinicians will be encouraged to ensure that all children of newly diagnosed PHLIV are tested, all in order to increase the number of children tested and the number of HIV- positive children diagnosed and linked to care. EID will also be re-enforced as discussed in the PMTCT section, and this will contribute to children initiating on ART.

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Challenges related to pediatric care and treatment

 The pediatric enrollment rate in CHASS is lagging behind. During TA visits, CHASS will train providers on the importance of testing more children and expand ROOT to additional sites in order to increase the number of children tested and the number of HIV-positive children diagnosed and linked to care.  Weak clinical services (e.g., CD4, pediatric growth monitoring) in the provinces is a challenge. CHASS will continuing using the QI cycle to address this and improve the quality of clinical care for children with HIV.  Not all children of adults receiving any HIV service (e.g., PMTCT, care, ART) are tested through index case testing.

Key pediatric care and treatment activities for the next quarter

 Expand ROOT to additional sites in order to improve coverage of all eligible children  Work with the Clinton Health Access Initiative (CHAI) and the CHASS lab team on the implementation of POC Polymerase Chain Reaction (PCR).  Work with the MISAU technical working group (TWG) to develop the family approach, in which mother-baby pairs receive services on the same day. Although this has not yet been approved, detailed planning and careful thought for all aspects of implementation are needed to ensure success. One issue CHASS will raise at these meetings is concerns around tracking retention of babies in mother-baby pairs. Because the baby’s chart is included in the mother’s chart, special attention is needed in EPTS sites to ensure that data for both members of the pair are updated, particularly given that there is no link in the EPTS. CHASS will also work to identify potential solutions to this problem in non-EPTS sites.

Laboratory Services CHASS support for laboratory services focuses on strengthening of diagnostic and patient monitoring capacities of HFs to enhance HIV case identification, initiation of eligible PLHIV on ART in a timely manner, switching of treatment regimens, and management of opportunistic infections.

Key activities related to laboratory services in Q2 included the start-up of implementation of provincial proficiency panels conducted by CHASS and the DPS to assess the quality of testing in all entry points performing rapid tests (i.e., maternal and child health [MCH], all HTC entry points). Five facilities in Tete and 12 in Niassa underwent this process in Q2, and their results will be shared in Q3. For the 32 sites that were evaluated in Q1, only two had an unacceptable level of testing, in both cases because they were not following the standard algorithm. As part of the follow-up of these sites, CHASS trained 192 health professionals in Manica in collection, processing, and transport of viral load samples. CHASS also re- enforced the MISAU algorithm through technical support visits (TSVs).

Performance in lab testing

In general, the number of samples sent for lab testing increased this quarter, with a more than 450 percent increase in viral load samples sent for processing (from 2,476 to 13,671), and a 15 percent 32 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

increase in CD4 samples (from 58,258 to 69,172).3 The huge increase in viral load testing was the result of expanded implementation and the fact that providers have begun requesting more tests following training and follow-up. The number of samples tested for TB using GeneXpert decreased by 3 percent this quarter due to the irregular functioning of the machine at Gondola District Hospital, which was not working during the months of January and February, and the failure of a module in the Eduardo Mondlane Health Centre; both of these facilities are in Manica. CHASS ensured communication of these issues to the company contracted by MISAU to provide maintenance of these machines. This decline occurred despite the addition of GeneXpert at two additional sites this quarter; the providers who had been trained required additional refresher training once the equipment arrived.

However, the number of samples sent is only one indicator of quality of care. Importantly, the results need to be received at the HF and made available to the provider for use during a clinical consultation. Data on the number of results received at HFs is more readily available. This quarter, 7,543 results (55 percent) of viral load tests were received at HFs. For CD4 counts, POC -CD4 (Pima™) equipment cut out the step of sending samples to a reference lab and provided more rapid access to results. Thirty-eight percent of all CD4 tests were processed using Pima™ at the 60 facilities where this is available. Getting the results into patient charts remains a challenge in some sites; CHASS is targeting this in Q3 to better ensure that providers have access to results when patients come for a consultation.

Challenges related to lab

 Not all providers have been trained in the use of viral load testing.  This quarter, the percentage of results received in Tete, which is served by the Quelimane Reference Laboratory, was particularly low (30 percent of viral load tests and 37 percent of PCR tests).  Systems for communication of results from labs to clinicians need further development.

Key lab activities for the next quarter

 Support the installation of the DISA Link program in the laboratory at the Provincial Hospital in Lichinga for the management of samples and results.  Continue to work with the Quelimane reference laboratory to ensure that samples from Tete are given the same priority as those from other provinces.  Strengthen procedures to ensure that lab results reach clinicians.

Pharmaceutical Care Systems and Services During Q2 of FY17, CHASS continued to strengthen pharmaceutical management processes to minimize stock-outs, improve quality of consumption reports, and reduce losses and expiry. Additionally, CHASS supported the strengthening of pharmacovigilance (PV) systems to improve patient care.

3 Results for PCR are discussed in the PMTCT section of the report. 33 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Strengthening drug and commodity management

CHASS continued to support drug and commodity management by promoting optimal medicine management practices, mentoring HFs for accurate consumption reports, and preventing stock-outs. During Q2, multiple stock-outs (7-35 days each) related to ARV drugs and rapid test kits (RTKs) occurred across the four provinces. Most of these events were reported at the provincial and district levels and did not affect service delivery. Where the problem affected HFs, CHASS pharmacy teams coordinated sourcing of products from other HFs while emergency supplies from the deposito provincial de medicamentos (DPM) were pursued. In Manica and in the context of increased testing, stock-outs of RTKs were more serious and may have affected the availability of services. The available stock was not able to satisfy the requirements and therefore necessitated prioritization by sector and site. This was as a result of 1) the intensified testing campaign, 2) delays in delivery from the central medical stores (Centro de Medicamentos e Artigos Medicos or CMAM), and 3) the incomplete supply of the requested quantities (e.g., 180 kits supplied versus a request of 680). The CHASS central-level pharmacy team worked with CMAM to facilitate the resupply of additional stock to the province and will continue to monitor the situation.

Training and mentoring of pharmacy technicians on drugs and commodity management: During Q2, CHASS pharmacy teams intensified mentorship and performed on-the-job training for 144 pharmacy technicians (Sofala: 53; Manica: 30; Tete: 46; Niassa: 15) in 60 HFs, deposito distrital de medicamentos (DDMs), and deposito provincial de medicamentos (DPMs) in the four provinces (Annexes 3 and 4). The training and mentorship focused on standard operating procedures for updating stock cards, accurate and timely updating of daily antiretroviral registers (LRDAs) and FILAs, and ARV and RTK consumption data report forms (MMIAs) from both the service delivery points to the pharmacy and from the pharmacy to the DDM/DPM. Additionally, CHASS pharmacy teams continued to provide TA through TSVs. The TA covered various aspects of drug commodity management including:

 Updating of stock and inventory status for health commodities using existing tools.  Accuracy and timeliness of commodity consumption reporting (e.g., LRDA, MMIA).  Implementation and management of the SIMAM system at the DDMs and DPMs.  Execution of health commodities distribution plans.

Support for health commodities distribution: During the quarter, CHASS supported the distribution of health commodities directly from the provincial level to the district level and from the districts to HFs. CHASS pharmacy personnel supported the review and execution of monthly distribution plans from the DPMs to the DDMs. CHASS also provided financial resources to the DPSs to facilitate transportation of the commodities to the various district-level warehouses. This quarter saw the complete transition of the medicines distribution support for the DPSs in Sofala and Manica from CHAI to CHASS. CHASS continued with the same approach of outsourcing transportation services with new couriers identified and contracted in the two provinces. CHASS will continue to monitor progress and make adjustments as necessary.

Consumption reporting for ARV drugs and RTKs: During Q2, CHASS provided technical support in the management of MMIA in 63 HFs (Sofala: 22; Manica: 28; Tete: 7; Niassa: 6). There were some incidents of delayed MMIA reporting in HFs in Sofala (Marocanhe, Macharote, and Phango) that do not have pharmacy professionals. The DDM usually sends pharmacy staff to support these sites during reporting, 34 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

but transport challenges this quarter meant that support teams could not reach the HFs in time. To prevent this in the future, CHASS will provide on-the-job training to the health workers in these facilities to improve their reporting capacity.

Implementation support for SIMAM logistics management system: During the quarter, CHASS pharmacy teams provided specialized support for the operation of the SIMAM logistics management information system in 12 DPMs, DDMs, and HFs where challenges were experienced. Additionally, CHASS continued to provide material support (consumables and Internet) for the timely updating of consumption data from HFs as well as medicine distribution schedules. Equipment operational problems were experienced in five sites, but this was resolved by facilitating repairs and system re-installation.

Implementation of electronic drug management system: During FY17, CHASS is working to procure and implement an electronic drug and medicines management system targeting 25 HFs across the CHASS provinces that currently have more than 2,000 patients on ART. Electronic systems will ease the dispensing process, improve drug management and the quality of the consumption and defaulter data reports, and improve adherence through reduced patient waiting time. Although the necessary equipment has been received, we are still waiting for the finalization of the pharmacy module that is to be linked to the existing EPTS. This process is expected to be finalized during Q3. CHASS M&E and pharmacy teams held consultative meetings with the partner designing the module to provide technical and design input. The discussions centered on the work flow at the pharmacy level and the various reports required as part of the pharmacy functions. The CHASS teams will continue engaging with the University of California at San Francisco (UCSF) as necessary during the process. The CHASS M&E team also worked with the partner developing the module to support the development of a training package for this new module at the request of the U.S. Centers for Disease Control and Prevention in Mozambique. Additionally, there is a newly introduced SIGLUS system that is being rolled out by CHAI with MISAU with U.S. Government support that is expected to provide real-time information on HF stock levels. The CHASS pharmacy and supply chain team will continue to explore how we can integrate this system.

Decentralization of ARV drug distribution and dispensing

To assist in reducing patient numbers at the pharmacy, CHASS is working toward establishing peripheral drug-dispensing outlets among the FARMAC chain of community pharmacies. CHASS is currently working on a study to determine the acceptability and feasibility of using these community pharmacies in the provinces as dispensing points. The protocol has been submitted to the FHI 360 institutional review board for approval, and we are in the process of finalizing the protocol for in-country institutional review board approval.

Support for the three-month dispensing initiative

As part of the differentiated care model, CHASS continues to support the three-month dispensing strategy implemented in participating HFs since August 2016. The aim is to decongest the pharmacies, reduce the frequency of travel to HFs for patients, and reduce waiting times at HFs, thereby enhancing adherence and retention. During Q2, 3,635 patients enrolled under the strategy at CHASS-supported facilities, bringing the total enrolled since the intervention started to 11,520 (27 percent). Table 10 shows the number of patients on three-month dispensing at the participating HFs. Although roughly half of the

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period covered by this strategy was in Q2, the percentage of patients who enrolled was lower because as saturation at sites was reached, fewer patients were eligible for enrollment.

Table 10. Number of patients enrolled in three-month dispensing in CHASS-supported HFs Province Health Facility Total FY17 Q2 Total Overall % of Active Patients Manica 1o Maio 428 1,625 28.6 Eduardo Mondlane 691 1,858 26.5 Niassa Cidade de Lichinga 646 1,179 51.4 Chiuaula 237 553 48.4 Sofala Ponta Gea 714 1,594 18.0 Nhamatanda 116 388 8.8 Tete Centre de Saude 3 571 1,340 27.4 Moatize 232 2,983 36.2 Total in Participating HFs 3,635 11,520 27.1

The eligibility criteria and identification of enrolled patients at the pharmacy continues to be a challenge, although there has been marked improvement. The improvement has mainly been the result of interventions put in place during this quarter that included active patient review by the CHASS clinical teams, ensuring that patients have updated CD4 results and the provision of job aids to facilitate interaction among the laboratory, clinicians, and pharmacies. The CHASS pharmacy and clinical teams will continue to provide TA and the necessary job aids to ensure that all eligible patients are enrolled at the time of eligibility and the appropriate records/registers are updated accordingly. An additional challenge is that many stable patients receive their prescriptions without a clinical consultation and, therefore, do not have recent CD4 counts, and CD4 count is a key criterion for eligibility. CHASS is working with HF staff to ensure that all potentially eligible patients receive a CD4 test so that their eligibility can be determined and they can be enrolled if appropriate.

The second phase of expansion of the three-month dispensing is expected to begin in May 2017. CHASS teams continue to engage the DPS to ensure the selected expansion sites are prepared with the necessary training and job aids.

Strengthening the use of FILAs to identify and track defaulters

CHASS pharmacy teams continued to support the accurate and timely updating of pharmacy-based patient tracking records and FILAs in 46 HFs (Tete: 9, Sofala: 17, Niassa: 8, Manica: 12) with a view of providing accurate information on defaulting ART patients (Annex 5). This has been a challenge, especially in the high-volume sites where the available pharmacy personnel are overstretched and in many cases unable to update the records daily as per the standard operating procedure. This has led to a situation in which some patients are classified as defaulters when they are not. Additionally, the methodology of completing the FILAs and LRDAs has changed in facilities where the three-month dispensing is being implemented.

During Q2, CHASS designed an intervention in which pharmacy personnel will be engaged for extra hours every day to ensure that all necessary pharmacy-based records are updated daily. This is expected to ensure accurate data for program decisions as well as accurate lists for defaulter tracing. The intervention will be implemented in Q3.

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Promoting and supporting pharmacovigilance and patient safety

In collaboration with the provincial PV focal persons, CHASS continued to support the PV system at the provincial level through on-the-job training and TA in the identification and reporting of ART-related side effects for pharmacy technicians and clinicians involved in ART care.

Improving and supporting adverse drug reaction notification: During Q2, 557 adverse drug reaction (ADR) notifications were received from the four provinces (Figure 12). Sofala and Manica surpassed the set quarterly target (121 percent and 136 percent, respectively). Tete and Niassa were below target (66 percent and 87 percent, respectively).

Figure 12. Number of ADR notifications in comparison to quarterly target by province, FY17 Q2

Implementation of a patient-focused PV package for health care providers: The patient-focused PV training and intervention package was meant to support clinicians in the use of ADR data to improve management of patients at the HF level, patient safety, and treatment outcomes. Following a national training of trainers in Q1, CHASS is working with the DPSs as well as the PV focal persons to organize provincial-level trainings targeting clinical and pharmaceutical personnel.

Due to the nature of PV reporting and the confidential nature of the notifications, we continue to engage the National Pharmacovigilance Centre to allow for availability and assessments of the notifications at the HF, district, and provincial levels. This will facilitate the use of the data to improve patient care.

National-level pharmacy-related activities

During Q2, CHASS teams participated in several pharmacy and supply-chain meetings. These included:

 U.S. Government supply chain partners meeting: Addressed the role of clinical partners in ensuring a well-functioning medicines and health commodity supply chain. The meeting also served to introduce the SIGLUS system.  Medicines TWG: Appraisal and approval of the terms of reference for the operation of the TWG and its various subgroups.

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 TB drug quantification TWG: Updated targets and discussed the transition of the management of TB drugs from PNCT to CMAM. The TWG also discussed the re-quantification of the DS-TB and MDR/XDR-TB medications.

Key pharmacy activities for the next quarter

 Intensify support for roll out of the three-month dispensing initiative in existing HFs and provide technical support for the expansion plans for new sites.  Follow up on the finalization of the pharmacy module for incorporation into the EPTS to ensure it serves the needs at the pharmacy level.  Strengthen the health commodity management systems to ensure continuous availability of medicines; intensify stock status reviews at all levels to reduce the incidences of stock-outs.

Prevention of Mother-to-Child Transmission Mother-to-child transmission is the primary mode of HIV acquisition in children, accounting for about 90 percent of cases. Therefore, the most efficient and cost-effective way to tackle pediatric HIV is to eliminate mother-to-child transmission. To contribute toward this goal, CHASS supports MISAU, DPSs, and SDSMASs to increase coverage of PMTCT services in scale-up districts. Additionally, CHASS PMTCT activities focus on 1) rolling out Option B+ to contribute toward the national target of reaching more than 90 percent of HIV-positive pregnant women, 2) increasing 12-month retention on ART among HIV- positive pregnant and breastfeeding women, and 3) improving follow-up of HIV-exposed infants with the target of covering 90 percent of them with cotrimoxazole preventive therapy and 90 percent with access to EID.

CHASS technical teams continued supporting efforts for rolling out Option B+ PMTCT services and improving EID testing. Within the three-month period, the number of HFs supported by CHASS that offer Option B+ increased by eight, with three sites in Manica and five sites in Niassa that had not offered Option B+ in Q1 reporting that it is offered in Q2. Three sites in Niassa had not previously received support from CHASS for ANC. At least one site in Manica began providing Option B+ in March; this site has some data on women receiving Option B+ but is not reported as a B+ site because it did not offer this service for the entire quarter. CHASS supported the expansion through training and mentorship on the new guidelines; provision of updated MISAU-approved materials on Option B+, including algorithms, job aids, and information, education, and communication; and provision of basic supplies like chairs and privacy partitions to facilitate the work.

CHASS also worked to strengthen male involvement in PMTCT this quarter, holding a training on this topic for two CBOs in Manica and providing them with a training on GBV during a TA visit from Dr. Tosin Akibu, gender specialist from FHI 360 Nigeria. In Niassa, efforts focused on Men to Men groups with one new group formed and two groups reactivated.

CHASS also worked to improve viral load testing for pregnant women by training MCH nurses in all four provinces in the collection and transport of samples. During TA visits, zonal teams also worked with MCH nurses to motivate them to request viral load tests for eligible pregnant women. Clinical charts of

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pregnant women were also reviewed, and those of women who were eligible for viral load but had not been tested were flagged for follow-up during subsequent consultations.

Performance in PMTCT

Between January and March, 101,298 women were registered in ANC services across all sites. The number registered was 4 percent higher than the number registered last quarter. Overall, 98 percent of these women (99,579) knew their HIV status (Table 10), a marginal improvement from 97 percent in Q1 but a continuation of an improving trend over time. CHASS is continuing to work with the DPS in each province and with HF staff to develop their capacity to accurately complete and summarize the new MCH tools, which has contributed to success in this area.

Among all of the women registered in ANC, 7 percent were determined (known to be or newly tested) HIV-positive (the same as last quarter); this percentage has ranged from 6 to 8 percent over the life of the project. Performance across the PMTCT cascade remained strong this quarter at the project level, especially in terms of enrollment of HIV-positive women in care (Figure 13). Again this quarter, there was a small increase in ART coverage of HIV-positive pregnant women, with 98 percent of HIV-positive pregnant women receiving ARV drugs compared with 97 percent in Q1; once again, this represents the highest level of coverage attained over the life of the project. The continued improvement is the result of efforts by zonal teams to further improve TA to HF staff, particularly regarding counseling and ensuring that all HIV-positive women seen in PMTCT are initiated on ART at the time of diagnosis. In Q2, CHASS intensified its TA, focusing on sites in conflict zones that had only received limited support previously as well as on sites with low performance in Q1. Meetings were also held with MCH nurses to encourage them to focus on complete registration, diagnosis, and immediate initiation on ART. CHASS counselors and psychologists have also been added been added at some sites, supporting MCH nurses in counseling for ART initiation. In general, improved relationships between CHASS and DPS/district supervisors has also led to better acceptance of CHASS TA by HF providers.

Figure 13. PMTCT cascade, FY17 Q2

Comparing the number of children under one year old who were tested for HIV via either PCR or rapid test to the number of HIV-positive pregnant women, 80 percent were tested—a decrease from the level 39 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

seen last quarter and the continuation of a declining trend. This decline is due to the increasing number of women in ANC. Because children are tested up to 12 months after birth (though about two-thirds are tested within the first two months), when the number of women in ANC increases, this measure of coverage decreases because the babies of these women will not be tested until the following quarter at the earliest. That said, CHASS continues to work to improve coverage of EID. The vast majority of infants seen in CCR units are tested. Although the data on the number of HIV-exposed infants registered in CCR have not been reviewed and corrected, as this is not a CHASS indicator, a rapid analysis showed that more than 100 percent of children registered were tested in all provinces; this was likely more than 100 percent because the denominator was incomplete. Testing coverage is also affected by the percentage of women who give birth in a HF. Depending on the province, only 51 to 75 percent of women with a birth in the past five years report giving birth in a HF.4 Ensuring that women who give birth outside a facility have their babies tested can be a challenge, although data from the Demographic and Health Survey (DHS) suggest that CCR coverage and the percent of women with births in a facility are not clearly correlated; the DHS data are, however, a bit out of date and may not reflect current practices since they cover births up to five years before the survey. CHASS is working with facilities to better ensure EID coverage by having MCH nurses maintain a notebook where they track all HIV-positive pregnant women seen in ANC to maternity and to CCR. If a woman does not bring her baby to CCR, the system of busca consentida is activated, with mothers called or visited to encourage them to bring their children for testing.

Among children tested this quarter, 5 percent tested positive for HIV—about the same percentage as last quarter. However, just 66 percent of the number of infants tested had results recorded at HFs—an improvement from 47 percent last quarter but still well below expectations. Again, these results highlight the ongoing problems with the PCR system since only 61 percent of PCR tests had a result delivered in the same quarter. In Q1, CHASS trained MCH nurses from both CHASS and CHASS-supported HFs to access PCR results on the website of the National Institute of Health to provide faster and more complete access to available results, and this may be responsible for the improvement seen. CHASS zonal teams also print results from the database and deliver these to HFs. CHASS is providing TA to sites to ensure that these results are then recorded in the livro de registo, and CHASS MCH nurses include this as part of their TA visits, identifying lab results and ensuring that they are recorded.

In addition to testing women who come for ANC and maternity services and their babies, PMTC services aim to test the partners of these women. A total of 27,926 partners were tested this quarter, meaning that partners of 27 percent of women registered were tested—a slight improvement from Q1 when 24 percent were tested. Positivity rates remained low among partners who were tested (3 percent). It should be noted that CHASS is following the agreement made at a meeting with MISAU that these data will not be reported under case index testing because partner testing in ANC has been a standard practice for some time and these results do not reflect the implementation of the index case testing approach.

Because retention data are collected on a semi-annual basis, data on retention are available for Q2 reporting. The cohort included in this analysis covered pregnant women enrolled on ART between September 21, 2015 and December 20, 2015. Overall, 63 percent of these women were active on ART 12

4 Source: 2013 Demographic and Health Survey 40 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

months after initiation—a rate lower than the rate among the population as a whole and a factor contributing to a lowering of the overall retention rate.

Variation by geographic area and Intervention

Although overall performance on the PMTCT cascade was strong, performance in Niassa showed room for continued improvement. Only 94 percent of women who were registered in Niassa knew their status (Table 11), and only 95 percent of those who were HIV-positive were on ART (Figure 14). This is, however, the best performance in Niassa to date over the life of project and reflects the attention CHASS has given to Niassa because of past underperformance. Particular focus was given to improving ART coverage among pregnant women in Niassa in both Q1 and Q2. Niassa’s improved coverage is also in part due to the expansion of Option B+ to sites where PMTCT was already supported but where only Option A was available previously. Moreover, while Sofala’s performance was high across the cascade, the fact that 7 percent of babies tested there were HIV-positive suggests gaps in the system that are not apparent from monitoring data. This may include factors like women starting on but not staying on ART. In fact, 12- month retention among pregnant women was lowest in Sofala, at just 57 percent (compared to a high of 75 percent in Tete).

Table 11. Performance of key PMTCT indicators by province, FY17 Q2 Target Achievement % of pregnant women with known HIV status 100% 98% Manica 100% 99% Niassa 100% 94% Sofala 100% 99% Tete 100% 99% % of HIV-positive pregnant women who received ARV drugs to reduce risk of MTCT 100% 98% Manica 100% 99% Niassa 100% 95% Sofala 100% 98% Tete 100% 99%

Figure 14. Option B+ coverage among HIV-positive pregnant women, by province and quarter

41 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

The low performance with regard to retention of pregnant women in Sofala is an issue that will receive increased attention in Q3. Following the CHASS strategy for improving retention among pregnant women, specific actions CHASS will take to address retention include enhanced post-test counseling for HIV- positive pregnant women in the context of PMTCT, continuing to support mentor mothers at the Super 16 sites, strengthening data for pregnant women, and busca consentida. Although CHASS has been supporting the implementation of mentor mothers since September 2016, training to mentor mothers was provided only in February in Sofala and in late March (Q3) in Manica. Mentor mothers in Tete and Niassa will be trained in Q3. As discussed in the Care and Treatment section, the updating of FILAs remains a challenge in many sites but is being addressed by CHASS through a new pharmacy intervention and by more regular review of these data by CHASS zonal teams. During site visits in Q2, CHASS noted that this is a particular issue for women in PMTCT in some sites as the FILAs are kept in the MCH unit so that they cannot be updated by pharmacy staff. CHASS is working with both the MCH nurses who keep the FILAs and pharmacy staff to improve this situation. Finally, busca consentida for pregnant and postpartum women on ART will continue with efforts to improve the percentage of women who are found. Our analysis for busca data (see IR3) shows that patients sought for PMTCT were less likely to be found than other groups (ART and TB/HIV). Improved counseling and psychosocial support through both additional CHASS counselors and capacity building of HF staff should also help to address this problem.

Performance against PMTCT targets

In terms of the number of pregnant women registered, CHASS achieved 117 percent of the target and 97 percent at DSD sites, but only 67 percent at TA sites this quarter. In TA sites, this was an improvement relative to the 62 percent achieved in Q1. Because performance against targets for all other PMTCT indicators is based on the number of patients registered, instead of analyzing performance against target, we are analyzing percent coverage here. Overall and in all provinces but Niassa, CHASS has all but achieved the target of 100 percent of women knowing their status. In reality, given that some women may refuse a test or may test in the following quarter after receiving permission from their mother-in-law or spouse, this level of achievement represents the maximum possible. Likewise, in terms of ART coverage, only Niassa and Sofala show room for improvement; in Sofala, 98 percent of HIV-positive pregnant women are on ART.

Relative to the quarterly target for infant testing (Figure 15), CHASS was on track overall again this quarter (at 88 percent of the quarterly target) but below target in Sofala (74 percent) and Tete (81 percent). The number of infants tested increased relative to Q1 in Manica and Niassa, remained the same in Tete, and decreased in Sofala. The decrease in Sofala was consistent with the two-week stock-out of tests that occurred this quarter. The reason for the under-performance in Tete is less clear, but the provincial team will target TA sites next quarter, as lower coverage there is limiting performance for the province as a whole. This will be done both as part of zonal team TA but also through targeted visits by CHASS MCH nurses to address this issue. A backlog at the reference lab in Quelimane affected the return of results for babies tested in Tete but did not affect testing coverage.

42 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Figure 15. Number of infants born to HIV-positive women who received an HIV test within 12 months of birth, FY17 Q2

Challenges related to PMTCT

 Niassa continues to have lower coverage of HIV-positive pregnant women with access to Option B+, with just 93 percent of HIV-positive pregnant women seen at facilities with Option B+, compared with more than 98 percent in the other provinces.  Niassa had issues with stock-outs of test kits at the facility level this quarter, limiting testing coverage. Anecdotal evidence also suggests higher refusal rates here— something CHASS will aim to document in Q3.  Retention of HIV-positive pregnant women is a challenge across the provinces.  Ensuring that HIV-positive infants are enrolled in care and treatment remains a challenge, both because not all infants are tested and because of delays in getting test results from the lab, and incomplete recording of test results.

Key PMTCT activities for the next quarter

 Continue expansion of Option B+ to more PMTCT sites. In Niassa, where the percentage of women with access to Option B+ is lower, CHASS is meeting with the DPS to discuss expansion of services with the aim of having all sites offering Option B+ by the end of 2018.  Conduct training of mentor mothers in Tete and Niassa and continue to support mentor mothers at the Super 16 sites.  Train additional cadres (e.g., Community case managers and Mentor Mothers) to provide psychosocial support and positive prevention to improve retention among pregnant women.

TB/HIV Integration To mitigate the potentially fatal effects of TB/HIV comorbidity, CHASS emphasizes the importance of TB/HIV collaborative activities across all supported sites, focusing on increasing early TB case detection 43 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

and treatment among PLHIV. Interventions include 1) intensified TB case finding among PLHIV; 2) HIV testing among TB patients; 3) institutionalizing infection prevention and control; 4) isoniazid preventive therapy, including ART for people co-infected with TB; and 5) strengthening HF and community linkages for effective TB case management.

In Q2, the TB/HIV technical officer started and focused efforts on infection control—an issue identified in Q1. The one-stop-shop model was expanded to an additional site in Sofala (Mutindir in Chibabava District). In Nhamahona, CHASS introduced a card into the patient files for tracking patients who are started on isoniazid for prophylaxis, in order to test this as a way to monitor prophylaxis.

Performance in TB/HIV Integration

The TB cascade (Figure 16) provides an overview of project performance with regard to patients co- infected with TB and HIV. This quarter, 5,839 TB patients were registered, and 99 percent of them knew their status at entry or were tested for HIV. Overall, 39 percent (2,214) were HIV-positive—a slightly larger proportion than in Q1. Furthermore, 96 percent of co-infected patients (2,135) had started on cotrimoxazole, and 90 percent (1,983) has started on ART— a continued increase from 80 percent in Q4 of FY16 and 87 percent in Q1 of FY17. As in Q4, the percent positive continues to be lower than expected (39 percent versus 51 percent; range of 28 percent in Niassa to 48 percent in Sofala).

Figure 16. TB cascade, FY17 Q2

TB case detection is the biggest challenge for CHASS and for the country as a whole with regard to TB and TB/HIV co-infection. Unfortunately, the number of TB patients registered declined this quarter (Figure 17). Although the reasons for the decline are not clear, addressing case detection is a priority for CHASS in Q3. Although the data may be underestimated due to incomplete registration, this is not likely to have a substantial effect on performance. CHASS is working with the FHI 360-led Challenge TB project in Mozambique to identify and implement approaches to improving TB case detection. The collaboration between the projects will focus on increasing demand at the community level in Sofala and Tete, where the two projects overlap, and on the expanded use of GenXpert. Moreover, CHASS will work with provincial TB supervisors in the DPSs in these provinces to increase TB screening in triage units by training providers to identify suspected TB cases (patients with recurrent respiratory infections). In the HIV sector, 44 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

CHASS is reintroducing a TB screening chart that was used in the past to encourage clinicians to identify suspected cases of TB. CHASS and Challenge TB feel that this will be more effective than simply including a check box for whether a patient is found to be positive or negative for suspected TB, given that the checklist is a job aid for providers to ensure that they are screening correctly.

Figure 17. TB patients registered, by province and quarter 7,000 6,452 6,046 5,838 6,000 5,345 4,934 4,932 5,000

4,000

3,000

2,000

1,000 # registered registered # in the TB sector

0 FY16 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY17 Q1 FY17 Q2

CHASS Manica Niassa Sofala Tete

This quarter, among new TB patients registered, 50 percent knew their HIV status at entry, and all but a handful of those who did not were tested for HIV. The percentage of patients who knew their status increased from last quarter, which may be the result of efforts to improve screening in the HIV sector. Among those newly tested, 14 percent (402 patients) were HIV-positive, and overall 39 percent of the newly registered TB patients were HIV-positive (Figure 16). As discussed above, the majority of co- infected patients started on both cotrimoxazole and ART. The improvements in enrollment are the result of improved reporting. Because TB/HIV co-infected patients are often treated in peripheral facilities but the TB registers are maintained in central sites, the data are not always up to date. CHASS is working to improve this. In Sofala, in Q2, all registered co-infected patients who did not have information on cotrimoxazole or ART were listed and were followed by community partners from Challenge TB to ascertain and update their status in the registers.

Variation by geographic area and Intervention

Quality of care for patients in the TB sector is consistently high in all provinces. However, Sofala is lagging behind in terms of the number of patients registered in the TB sector (case notification), having reached only 80 percent of the target this quarter and continued a declining trend in the number registered since Q4 of FY16. This is the result of insufficient screening patients in the HIV sector. Some of the efforts to address this are described above; however, in addition, in Sofala CHASS and Challenge TB are introducing the FAST (Finding Actively TB and MDR-TB cases, Separating safely, and Treating effectively) strategy by training CHASS CBO staff (case managers, counselors and activistas) to use FAST at entry points, in waiting rooms, during health talks, and during household visits (for counseling, psychosocial support, or busca consentida). Suspected cases will then be referred to clinicians for further screening and diagnostic

45 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

testing. In terms of enrollment on ART of patients who are co-infected, Tete is behind the other provinces at 84 percent. CHASS is following up on the reasons for this.

Performance against TB/HIV targets

This quarter, performance with regard to the number of TB patients registered was 96 percent of the quarterly target overall. However, performance in Sofala was 80 percent of the target (discussed above). Performance against the targets for other TB indicators can only be considered within the context of the number of patients registered, as this is the denominator for all other indicators. Performance is generally consistent with targets once this first target is met, given that almost all patients are tested and that coverage of CTX and ART are high among co-infected patients.

Challenges related to TB/HIV

 Although the quality of services for co-infected patients (e.g., initiation of ART, prophylactic therapy with cotrimoxazole) are better, the rate of TB screening remains low.

Key TB/HIV activities for the next quarter

 Collaborate with Challenge TB to strengthen referrals of suspected cases from the community to HFs.  Expand use of GeneXpert (as the exam of choice) in HFs where it is available.  Reintroduce the TB screening tool in ART consultations to ensure more complete and accurate screening of HIV-positive patients.

Nutrition Support

The CHASS nutrition support program aims to strengthen nutritional care for PLHIV in clinical and community-based services in accordance with the national guidelines. The project supports the implementation of the Nutrition Rehabilitation Program (NRP) volumes 1 and 2. Emphasis is placed on screening PLHIV for malnutrition, nutrition counseling, and nutrition support using corn and soy blend plus supplementation provided by other partners. CHASS also supports the rollout of the Baby-Friendly Hospital Initiative of MISAU. Additionally, CHASS supports community interventions to improve access to integrated care, treatment adherence, and health outcomes of PLHIV.

In Q2, CHASS collaborated with the four DPSs to conduct nutrition assessments at 15 of 16 priority sites using the MISAU “Quality Standards for Measuring Performance of Nutrition Rehabilitation Program Services,” which evaluates equipment and support materials, clinical assistance, human resources, logistics, and M&E in five sectors: ANC, CCR, well-baby clinics, pediatric wards, and postpartum services. These assessments are designed to assess the performance of HFs with regard to provision of the NRP. Only one site—Manga Mascarenha in Sofala—obtained 100 percent of the standards in the majority of sectors assessed (all but postpartum care). All other sites underperformed (achieving less than 80 percent of the standard) with regard to pediatric consultations, and most underperformed in postpartum care (10/13) and ANC (11/13) (one site did not offer postpartum care or ANC). The reason for underperformance was a lack of equipment and support material, which CHASS is currently procuring.

46 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

As part of the PEPFAR Drought Response, CHASS and the FHI 360 FANTA III project collaborated to train 94 health providers on NRP I and II (60 from Tete in February and 34 from Manica in late March). The training aimed to increase the health staff’s knowledge and skills in applying PRN protocols. Additional training on QI methodologies was provided to bring about changes in the PRN performance results. CHASS also trained 57 health providers on NRP II in Niassa in late March. Because nutrition indicators were removed from the MER indicators in September 2016 and no guidance was given that these indicators would be continued as Mozambique-specific indicators, CHASS stopped providing full support to the reporting of these indicators in Q1, as we had not been given any guidance that they would be reported after Q4 of FY16. With the advent of the PEPFAR Drought Response, CHASS will be providing additional support for the recording and reporting of these data.

During their TSVs to HFs, CHASS zonal teams continued to follow up and mentor HF workers in integrating all elements of the national nutrition rehabilitation plan into the care and treatment of PLHIV. Specifically, CHASS teams emphasized nutritional screening of all PLHIV, nutritional counseling, and prescription of nutrition supplements to boost the nutrition of malnourished adults and pediatric patients.

Challenges related to nutrition

 A lack of anthropometric tools at HFs.  Integration of the NRP in VTC has not been a focus of CHASS zonal teams due to many competing priorities.

Key nutrition activities planned for next quarter

 Strengthen the technical capacity of health providers to implement the NRP integrated in care and treatment of PLHIV using the QI strategy in accordance with the directives issued by MISAU.  Replicate MISAU training on stock management of nutritional supplement and treatment (planned for June) with involvement of CMAM to ensure the entire logistics chain at all levels.  Reinforce TA in drought-affected sites for both clinical care and documentation of services provided.

Gender CHASS underscores the linkages between gender and HIV. As such, the project prioritizes gender programming as a cross-cutting element in HIV prevention, care, and treatment. CHASS pursues this objective through training and mentoring HF staff and community actors to effectively integrate gender in service delivery. Screening PLHIV for gender-based violence (GBV) and providing or referring GBV victims for post-GBV care is a hallmark of the CHASS gender strategy.

During Q2, the CHASS gender and youth team supported MISAU to implement strategies for the integrated assistance of victims of GBV in all four provinces. The activities focused on raising awareness of GBV services andd overcoming barriers to use of these services. The capacity of GBV service providers was re-enforced through on-the-job training for health professionals in coordination with the Office of the Attorney General and the Department of Gender and Social Action. The training, which included MCH

47 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

nurses, psychosocial technicians, emergency service providers, and youth-friendly service personnel, focused on:

 How to complete GBV notification forms.  How to check and organize post-exposure (PEP) prophylaxis kits.  Flow of assistance to victims of GBV.  Provision of referrals and counter-referrals for victims of GBV to and from HFs.

CHASS supplemented the training slides with information on GBV cases and algorithms for assisting victims of rape with the aim of improving case management. Other activities included dissemination of GBV information, education, and communication materials and demand creation for voluntary medical male circumcision services.

In Q2, CHASS and MULEIDE conducted a number of trainings including a start-up training for MULEIDE staff and CBOs, and a training for MULEIDE community mobilizers. All of these trainings supported the expansion of community-based activities on gender and GBV.

In March 2017, FHI 360 Gender Department Director Andrea Bertone conducted a rapid gender analysis with key CHASS staff to explore gender-related reasons for low pediatric and adolescent adherence to ART. Approximately 15 focus group discussions were organized in Sofala and Manica provinces with women who have children under five, men who have children under five, grandmothers/mothers-in-law, adolescent girls and boys, and traditional healers. The groups were asked questions aimed at determining the gender dynamics among men, women, boys, and girls related to taking decisions about health- seeking behaviors, their roles and responsibilities in the family and community, access and control over resources, health care, cultural norms and beliefs, and patterns of power.

Primary findings included the following:

 HIV is still tremendously stigmatized in Mozambique. People do not have multiple sources of information about HIV. They are primarily hearing about it from a lecture at the hospital. It does not appear to have a great deal of coverage by television, radio, or print media. The social media landscape is changing, and young people are more frequently turning to those sources of media. However, the extent to which young people are receiving accurate information about HIV prevention and treatment is unknown. This needs to be further investigated.  Young people may not take HIV as seriously as they should, or they may sink into despair at the idea of HIV. Both responses show a lack of knowledge about the disease and its treatment, as well as a lack of maturity. Activities that would allow young people to discuss these issues and questions they might have in a safe and welcoming environment would help to shape adolescents’ positive attitudes about HIV.  The fact that women do not want to reveal their status to their husbands is a serious gender dynamic that contributes to loss to follow-up and poor adherence.  We need a much more robust engagement with men and boys. A few fathers’ group discussions will not be sufficient. These discussions have to be targeted around HIV-positive status and prevention of GBV. The discussions have to be facilitated by trained community facilitators.  The dynamic of mothers-in-law as influential in the lives of their daughters-in-law emerged during focus group discussions. 48 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Although the findings were inconclusive regarding the relationship between gender and low adolescent and pediatric adherence to ART, information gleaned through focus group discussions can be used to strengthen the CHASS project. The information can assist in development of a more robust level of engagement at the community level to address misinformation and stigma about HIV, traditional roles, responsibilities, and beliefs among men, women, and adolescents about HIV that prevent adults from adhering to ART (which may be related to why children are not adhering to the ART regimen).

Performance in GBV

A total of 944 people were reported to have received post-GBV services this quarter across the four provinces, and 182 of them had received post-rape care (Table 12). Among those who received post-rape care, 175 (96 percent) were tested for HIV, 100 (55 percent) received PEP, and 64 (35 percent) received emergency contraception (EC). In all provinces, the percentage of victims of GBV who received PEP was lower than hoped because people came for services at the HF after 72 hours. The percentage who received EC may also be lower than expected, but this is due to some women seeking eligibility too late and others being young girls who are not yet menstruating and are, therefore, not eligible to receive EC.

Table 12. Number of people treated for GBV services and services provided by province, FY17 Q2 Province # of people receiving post- # of people receiving post-rape care % of people receiving other GBV care post-GBV care # % male % # # tested # # # # # % % children for HIV received received received received received received PEP EC PSS referrals PSS referrals Manica 265 9% 24% 88 84 49 41 84 82 172 62% 67% Niassa 213 34% 8% 14 13 11 9 14 11 199 88% 65% Sofala 190 23% 19% 64 63 40 30 64 57 126 97% 100% Tete 276 34% 14% 16 15 0 0 0 0 260 1% 98% Total 944 24% 17% 182 175 100 64 162 150 757 54% 83% Abbreviations: PSS=psychosocial support.

The percentage of people who received post-GBV care who were under age 15 ranged from 8 percent in Niassa to 24 percent in Manica. The percentage of victims of GBV who were male ranged from less than 10 percent in Manica to 33 percent in Niassa and Tete. This may reflect some misreporting of GBV, as the tools that are used record all violence and providers must specify if a case is GBV. We believe that the new tools, which will be rolled out in Q3, will help to address this problem. However, at least in Niassa, data from the DHS also support relatively high rates of GBV against men, which may result from the matriarchal society there.

Among the 757 people who received other post-GBV care, psychosocial support and referrals were the most commonly received services, although there was huge variation across provinces. Overall, just 54 percent of all victims of non-rape GBV received psychosocial support; although only two people received this psychosocial support (PSS) in Tete, 97 percent did in Sofala. The percentage covered in Manica was also low at 62 percent. Referral coverage was also low in both Manica and Niassa, at below 70 percent. In fact, we believe this reported coverage does not reflect actual performance and is, instead, a reporting problem. CHASS will give focused support to this issue in Q3.

Challenges related to gender

 Lack of HIV knowledge among adolescent girls and young women and their partners. 49 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

 Poor involvement of male partners during women's consultation and follow-up visits.  Misconceptions in communities, particularly of mothers-in-law with regard to HIV treatment and follow-up.  Poor awareness of the need for GBV referral from the community to HFs.  Victims of rape are delayed in reaching the HF as they often wait to resolve the issue in the family or in community courts before attending a HF. This delay limits the use of PEP and emergency contraception as they arrive too late to receive these services.  Poor follow-up of patients exposed to GBV who have received PEP.

Key gender activities for the next quarter

 Provide evidence-based guidance to CHASS provincial teams on effective strategies for engaging male partners; advocating for men-friendly services at the Super 16 sites; facilitating monthly community meetings with influential male leaders; and targeting male-dominated workplaces with comprehensive messages and services on HIV/AIDS.  Strengthen community partners’ capacity to build awareness of and address gender norms that affect HIV, to support male involvement, and to provide support for victims of GBV in communities.  Support MISAU in training, disseminating, and operationalizing the new GBV instruments; CHASS has already started reproducing these materials for dissemination.

Health System Strengthening

The CHASS Project’s HSS strategy is grounded in Abt Associates’ System Capacity Builder Approach (SCBA) to strengthen district health systems and improve HF management of HIV services. The SCBA maximizes progress toward achieving the 90:90:90 targets by strengthening site, district, and provincial health managers’ capacity to more effectively respond to HF needs to provide high-quality HIV services. Quarter 2 was primarily dedicated to increasing the coverage and quality of the HF-level Management Strengthening Intervention Package targeting sites burdened with long waiting times, unevenly distributed and inefficient patient flow and client services, and weak provider-client relationships. Initial results showed reductions in waiting times and improvements in HF organization and cleanliness, with concomitant increases in patient satisfaction as the consultation appointment system further reduced waiting times, improved site efficiency, and strengthened patient-provider relationships.

Governance and leadership at DPS, SDMAS, and HF levels

In Q2, CHASS consolidated the implementation of the HF-level Management Strengthening Intervention Package targeting high-volume urban scale-up sites to improve site management, organization, and efficiency of HIV service delivery. The package includes four diagnostic tools to measure overall site management and the efficiency of HIV service delivery points, as well as a menu of four discrete interventions that are applied based on the results of the diagnostic tools in order to strengthen management and improve efficiency.

As outlined in Annex 6, the intervention starts with a HF institutional assessment to identify opportunities for improvement. This was completed at all 49 of the targeted high-volume urban scale-up sites in the 50 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

provincial and district capitals by the end of Q2. Diagnostic assessments of patient waiting times (n=27), patient satisfaction (n=25), and patient flow and the location of HIV service delivery points (n=16) followed. The results of these diagnostic assessments were analyzed together with HF staff to identify bottlenecks5 and areas where patients have a high risk of being lost to follow-up or coming into contact with highly infectious patients (e.g., TB ward), as well as to assess whether the existing flow for the provision of HIV services was efficient, timely, and aligned with the latest MISAU standard operating procedures. Patient satisfaction data, including client opinions and suggestions for improvements, were also analyzed to identify potential solutions that might increase user satisfaction and adherence to HIV services.6

The results were the basis for QI action plans that addressed identified needs. Where appropriate, these were linked with the available HF-level sub-agreement funds to purchase equipment and services. Key areas for improvement for which plans were developed and implemented included:

 Improved patient flow and easier access to routine clinical instruments.  Improved management of the reception area, and a reduction in the time required to pull a patient’s file from the archives.  Long waiting times and inefficient patient flow.

Preliminary findings show a 62 percent reduction in average waiting times, suggesting improvements in the efficiency and management of HIV services, with. Qualitative interviews of providers and patients suggested increased motivation following implementation of the plans.

During the quarter, the CHASS zonal teams also prepared 16 district profiles that were used in discussions of strategic information at the CHASS-funded quarterly district data review meetings with district managers and HF representatives. The meetings included the joint identification of opportunities for improvement, which were then included in QI action plans drafted during the meetings to guide the continuous implementation of corrective actions until the next quarterly meeting.

Logistics supply chain management

Ensuring uninterrupted access to essential medical products (e.g., drugs, vaccines, test kits, reagents) and laboratory services is critical to enable scale-up districts and sites to achieve the 90:90:90 targets. In addition to the assumption of support for transportation of all consumables and medications from provincial to district level depots discussed in the Pharmaceutical section of this report, CHASS also continued to update existing supply chain management route maps and schedules to incorporate new ART sites in six scale-up districts in Tete and Niassa Provinces (Annex 7). In addition, the project implemented the 5S QI Program in two DDMs in Sofala and Tete and in the DPM in Lichinga, improving inventory management and access to essential commodities and medications. Routine weekly inventory monitoring and TA was also provided to Test and Start sites to ensure these high-priority HFs always had access to essential medications, reagents, and rapid tests. When necessary, CHASS supported the

5 Common bottlenecks identified included high volume days during the week, particularly Mondays and Fridays; long waiting times to find HIV+ patient files; low percentage of eligible patients on the rapid flow (fluxo rapido); etc. 6 Common concerns included long waiting times, inadequate patient triage, lack of privacy, poor site hygiene / cleanliness, inadequate signage of services, poor ventilation of consultation rooms, common stock outs of certain medications, and lack of functional bathrooms. Common areas of satisfaction included HCW bedside manner, clarity of the clinical instructions and explanations, and efficiency of one-stop model with all services in one clinical visit. 51 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

redistribution of consumables between HFs to reduce the risk of stock-outs and expiration of commodities when stocks were low. The project also updated the inventory of vehicles responsible for supporting the distribution of medications, consumables, and lab samples and results for all provinces and districts, sharing the results with the U.S. Government logistics technical working group.

In terms of HF maintenance support, following the completion of the bills of quantities and publication of tenders in Q1 to contract companies to implement site repairs and respond to equipment needs, CHASS implemented HF rehabilitation projects at 34 sites in Q2. Support included, for example, the division of consultation rooms to expand the available space for private HIV consultations and HTC; installation of AC units at multiple sites for DDMs, public pharmacies, and labs; installation of water tanks and pumps to improve access to water at multiple sites; installation of security bars to ensure critical equipment is protected from theft; installation of patient file archives; and painting of HIV service delivery points.

Financial management

The project strengthens financial management by using the CHASS provincial and district sub-agreements to track and improve DPS and SDSMAS adherence to Government of Mozambique financial management procedures in collaboration with the government compliance department. During Q2, CHASS worked with Niassa’s internal audit department (Gabinete de Inspecção) to conduct an inspection visit at the Lichinga City SDSMAS. The audit did not identify any major inconsistencies. The project also supported SDSMAS and HFs in 12 districts to improve the efficiency of implementation and management of the CHASS sub- agreements. These improvements, for instance, enabled two districts to save enough funds to purchase a photocopy machine (in the case of Lichinga) and finalize the construction of a meeting room (in the case of Mecanhelas). CHASS also provided technical and financial support to the Manica DPS for the finance and administration department’s annual planning and performance review meeting, which culminated in concrete action plans to improve financial oversight and management.

Human resources for health

CHASS is investing in Human Resources for Health (HRH) towards an AIDS-free Generation by building HRH management skills and service provision capacity. During the period under review, CHASS focused its HRH support on rolling out the new incentives program recognizing the achievements of health care providers with strong performance. The most noteworthy progress was made in Tete City, where the DPS and scale-up SDSMAS successfully formed provincial and district evaluation committees in collaboration with the CHASS project. The provinces of Manica, Niassa, and Tete are currently in the process of acquiring the agreed upon prizes to increase HRH motivation. The project also provided routine HRH TA to 12 districts during the quarter, strengthening organization and completeness of personnel files and HRH manager compliance with MISAU standard operating procedures. In most instances, this also involved updating the quarterly district in-service training plan, ensuring that it is tailored to the district- specific training needs as guided by the percent of eligible providers at ART sites that are trained in HIV/AIDS care and treatment services. Overall, by the end of the quarter, 226 staff had received in-service trainings at the district level via CHASS sub-agreements to strengthen capacity to achieve the 90:90:90 objectives. An additional 674 health care providers were also trained at provincial and community levels. Annex 8 outlines the specific themes and number trained in each province by funding mechanism, all of which were reported in the MISAU’s in-service training information system and USAID’s TraiNet with support from CHASS. 52 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

In terms of provincial-level HRH support, CHASS supported the DPS in Manica Province to conduct the annual HRH planning and performance review meeting, which culminated in an updated 10-year plan (2016-2025), as well as an action plan to close the gaps in terms of in-service training needs based on the percent of staff at ART sites that are trained in HIV competencies.

In terms of pre-service training, CHASS continues to support 185 students across five courses in Manica, Sofala, and Tete, including 61 medical technicians, 96 MCH nurses, and 28 laboratory technicians. These students are expected to graduate before the end of the CHASS project in June 2018.

Private-public partnerships

CHASS is using private-public partnerships to contribute toward PEPFAR 3.0’s Partnership Agenda to achieve greater impact and sustainability through private-sector engagement in the delivery of HIV care and treatment services. Following the signing of the private-public partnerships in FY16 Q4, the National HIV Program requested an additional memorandum of understanding between CHASS and MISAU in FY17 Q1. By the end of Q2, the Minister of Health, through the National Director for Planning and Cooperation, communicated to the CHASS project that the MISAU was prepared to sign off on the memorandum of understanding with FHI 360. In addition, by the end of Q2, the last remaining private health care providers at Companhia de Vanduzi in Manica Province were trained in MISAU’s standard in-service training package for HIV care and treatment service delivery. The only remaining step required before HIV/AIDS care and treatment services can begin to be provided at these three private-public partnership private clinics is for FHI 360 to sign the memorandum of understanding with MISAU.

Quality Improvement CHASS QI efforts aim to define context-specific approaches to ensure that HFs meet national standards for HIV care and treatment. This entails frequent measurement of the standards related to HIV service delivery. During TSVs, CHASS zonal teams review practices against standards of care. Findings serve as the basis to develop action plans, jointly with HF staff, for improvement. CHASS’s goal is to achieve performance greater than 90 percent on all QI indicators. Apart from monitoring adherence to clinical care standards, CHASS pursues QI by promoting humanization of services at the HF level. The two approaches are consistent with national QI guidelines.

During the quarter, CHASS participated in the implementation of the final phase of the first QI cycle and the preparation of the second national QI cycle. As guided by MISAU, the first cycle, which initiated a year ago, has to be completed before the second cycle can begin. A final assessment of the first cycle needs to be conducted and will be considered as the baseline for the second cycle. In this regard, all HFs implementing the national QI approach were finalizing the first cycle and preparing for the second cycle through trainings and orientations. CHASS supported the four provinces, ensuring technical and logistical capacity through training and offering all needed resources. At the national level, the CHASS senior technical officer participated in MISAU-led QI activities including 1) developing training materials, 2) elaborating the details of the orientation for the provinces, 2) revising QI tools for the next phase, and 3) recycling and updating provincial QI trainers through refresher trainings.

53 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

In terms of CHASS-specific QI activities during the quarter, the CHASS quality assurance team focused on implementing various plan-do-study-act (PDSA) cycles to test interventions that address gaps observed by external TA providers from the FHI 360 global team or identified by the CHASS teams during performance measurement. The CHASS central team also supported the provinces to improve performance through TA provided by a “national task force” that helped provincial teams to define key areas for improvement and develop and implement the means to address them.

One key examples of the use of PDSA cycles was for PICT as described in the HTC section of the report. The team focused on training providers to offer PICT and tracking their performance. This approach led to a 50 percent increase in the number of people tested in PICT across the provinces, with a 73 percent increase in Sofala. This new approach promotes PICT through PICT workshops, which are followed by monthly meetings to evaluate implementation and share lessons learned.

PDSA cycles are also being used to improve linkages from testing to care. After defining this as a gap, a system of escorting patients from diagnosis to care was designed. Case mangers serve as the escort in most cases, although in some HFs and sectors clinicians are also acting as escorts. As a result, we saw an overall improvement in the four provinces. More specifically, Qi data from three HFs in Chimoio showed improvements in all sites and a more than a 40 percentage point improvement in 1o de Maio (Figure 18).

Figure 18. Percent of all newly diagnosed patients linked to care and treatment in select facilities in Chimoio City, by month, FY1 Q2

Key quality improvement activities for next quarter

 Roll out the training package for the second cycle of the MISAU-led QI approach.  Finalize the first national QI cycle and the baseline assessment for the second cycle in selected HFs.  Continue to support CHASS provinces (CHASS and DPS staff) in implementing PDSA cycles to improve performance on priority indicators and to use cascade analysis to identify gaps and opportunities for future PDSA cycles.  Based on the results of this quarter’s analysis, the national task force will work with provinces to address key areas in need of improvement.

54 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

IR2: STRENGTHEN COMMUNITY-BASED HIV SERVICES – ACCESS, QUALITY, AND RETENTION

Activities implemented under IR2 of the CHASS project aim to provide high-quality, coordinated, community-based HIV services to enhance PLHIV access, retention, and adherence to ART. Ensuring access to quality services and retention of clients is done through various combined strategies including community mobilization, C-HTC, and community-based care to enhance treatment adherence and retention as well as linkages with HFs.

Community Services to Support Retention CHASS continued to support a package of community services that includes early supportive visits to newly diagnosed HIV-positive patients by activistas concentrated during the first three months of ART initiation. The content of the visits includes reinforcing ART literacy, adherence counseling, disclosure, and psychosocial support and positive prevention.

Household visits

Household visits are especially important in “Test and Initiate” sites, where many people are initiating ART when they feel well, putting them at higher risk of defaulting. These visits include pre-ART patients, whereby patients who test HIV-positive and are at risk of not returning within 15 days to initiate treatment are visited at home. CHASS has instituted early and intensive home visits (or calls) in the first three months after initiating treatment, starting in the first 48 hours for those at higher risk for defaulting. This was instituted in Test and Initiate sites, as this is the period when side effects begin to occur; thus, early visits are considered crucial to treatment success. Activistas use these visits as opportunities to verify whether the PLHIV have disclosed their status to their sexual partners and whether their partners have been tested. Home visits also provide an opportunity to reach and retain more men.

In Q2, 10,938 household visits to 7,620 patients were reported. A total of 4,359 first visits were made, compared with 21,319 new enrollees. This was 20 percent of all new patients this quarter. Although some patients refused to be visited for reasons of confidentiality and others were at low risk of defaulting, this level of coverage was below our expectations and may reflect 1) continued implementation of the MISAU calendar and a less intensive approach to visits; 2) lack of operational systems in place to activate and report visits; 3) lack of prioritization of this activity, as activistas are also asked to focus intensively on buscas to increase the number of new patients initiating ART (a reportable indicator); 4) visits carried out using another modality that does not get recorded, such as a phone “visit” or 1,197 children under age 15 were visited incorporating the first visit into the community counselor’s in Q2. This is 16% of all new people index case contacts visit; and 5) underreporting. This requires visited. additional follow-up to determine the extent to which this 6,423 females were visited. This was 62% reflects underreporting and the extent to which it is a of all new enrollees. problem with implementation of planned activities. Data on household visits were reported by CBOs associated with 123 different HFs of the more than 346 CHASS-supported ART sites. Among facilities covered, 59 facilities had data reported in all three months, whereas 38 facilities had data reported in two months of the quarter 55 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

and 26 only in one month. In some cases, data were not reported for a given month because visits had not yet started. Among the visits that were reported, 41 percent were reported to be initial visits and 59 percent repeat visits. Among those who were visited, 38 percent were male, 62 percent were female, 16 percent were children, and 84 percent were adults. Given that only 7 percent of new enrollees were children, this suggests that children are being prioritized for household visits.

The existing MISAU system for home visits is dependent on the PSS focal point to manage visits. This includes “activating” or requesting a visit, distributing the list to the community case manager for distribution to activists, receiving results, and summarizing the results into a monthly reporting form. CBOs then enter this information into the database. This is challenging in sites where providers are spending less time per patient because of pressure to rapidly start people on ART, and may be a particular challenge in “one-stop” areas where clinicians are carrying out the role of both provider and PSS. On the other hand, we have reports that many “one-stop-shops” are better at requesting visits than are clinicians providing the standard outpatient consultation. Because providers (including PSS) provide comprehensive care in these sites, they may be more in touch with patients' risk factors for non-adherence. Activists are trained in the MISAU calendar of home visits within 15 days of initiating treatment to those at risk for non-adherence (two risk factors or more), concentrated in the first 3 to 6 months of treatment, and forms have been designed accordingly. As CHASS is encouraging earlier and more intensive visits to new initiates as described above, this requires re-designing monitoring and data collection systems and re- orientating all actors (e.g., CBOs, activistas, community case managers, PSS focal points), including clinical staff.

Various innovations were piloted this quarter to promote, reinforce, and manage early visits to a large number of new ART initiates:

 New forms were piloted in one T&S HF in each province, with the more intensive visit calendar.  In Manica Province, activistas escorted very high-risk patients to their homes. During this first support visit the activista verified the address (a challenge for visits and searches) and evaluated various risk factors including family support and disclosure status. They also linked the patient with a community counselor as an index case so that sexual partners and children could be tested. The visit of the community counselor served as a second support visit. It was found that, even in urban settings, activistas were only able to escort an average of three patients per day, so the CHASS is considering increasing the number of activistas commensurate with targets and providing a transport fund, as distances (even in urban settings) require use of paid transport. This will be contextualized to each setting.  In Sofala, external teams of PLHIV model patients were used as additional human resources to respond to the fluctuating need for visits and searches. For example, after a short training these teams were successfully used to search for 89 pre-ART patients in Beira, 63 of whom subsequently returned to care and initiated ART (a 71 percent return rate). This is similar to the general return rate with searches carried out by activistas this quarter. However, cost of transport was also mentioned as a limiting factor during this exercise.

Increasing the proportion of new ART initiates receiving home visits is challenging in sites where providers are spending less time per patient because of pressure to rapidly start people on ART, and is a particular challenge in “one-stop” areas where clinicians are carrying out the role of both provider and PSS. Where

56 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

there is inadequate time for PSS, patients do not receive adequate preparation for initiating ART (treatment literacy), may not undergo a full PSS risk evaluation (which is important for determining need and consent for a home follow-up visit), and may not have time for filling out the forms and registers necessary to activate the visit. CHASS is working with MISAU on the concept of a reduced PSS package that includes key messages essential to adherence and retention, to more effectively focus scarce human resources.

Strengthening technical capacity of CBOs

In order to improve the quality of community activities, CHASS provided resources to each CBO to hire technical supervisors who will guide implementation of community activities with oversight from CHASS staff. These staff were selected with CHASS participation and oriented by CHASS staff this quarter. CHASS staff will continue to strengthen CBO capacity for technical supervision.

CHASS provincial teams are increasingly implementing the integrated supervision strategy in which CHASS community staff as well as CBO supervisors carry out joint visits to each priority site, at least quarterly, within the zonal team framework. Results are discussed within the team, which includes clinical, M&E, and program management staff, in order to establish a common action plan. DPS and SDSMAS community staff will also be increasingly included.

CHASS has increased subsidies in order to recruit and retain capable lay staff. This includes higher subsidies for phone “visits” and “searches” to help retain the high numbers of patients initiating ART. Tighter management systems were put into place to improve quality and accountability. Community case managers will now be present during the entire HF workday, including in those HF sectors that are instituting flexible working hours.

Village savings and loan clubs

CHASS is working in communities to organize VSL groups as a way to support PLHIV with economic strengthening activities that may help them overcome some of the barriers to adherence and retention in care as well as reduce stigma. CHASS continues to support more focused recruitment of VSL members. While recognizing that mixed (PLHIV and non-PLHIV) membership may reduce stigma, CHASS is striving to increase PLHIV membership in groups to at least 60% and achieved 50 percent PLHIV this summer (Table 13). Members are referred by case managers but are also identified through mobilization sessions in HF waiting areas. VSL members report advantages of membership include: improvement of financial conditions, availability of loans for business and increased resources for transport to the HF.

Table 13. Proportion of VSL members who are PLHIV, by quarter, FY17 Province # of GPCR # of Members # of PLHIV % PLHIV Members Manica 83 1550 682 44% Niassa 52 1184 592 50% Sofala 112 2165 1191 55% Tete 72 1535 783 51% Total 319 6434 3248 50%

At the end of Q2, the proportion of VSL members who were PLHIV increased by 1-2 percent in Sofala and Tete and by 10 percent in Manica (34 to 44 percent) but decreased from 60 to 50 percent in Niassa. In 57 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Niassa, recruitment was focused on increasing the number of members but not on including PLHIV. CHASS will provide refresher courses to CBOs and their Community Facilitators next quarter, which will include effective recruitment strategies.

To enhance cohesion and promote retention in mother-to-mother groups CHASS linked Economic Facilitators with Mentor Mothers in five districts in Sofala incorporating mothers into VSL groups as well as providing health education sessions addressing the importance of ART adherence and other topics important to treatment success. In Sofala Community Case Managers were invited to VSL groups to lead health education sessions about HIV and ART retention, providing higher quality information to enhance retention among VSL’s PLHIV members than when activistas or economic facilitators lead these discussions. Lessons learned will be shared at a national CHASS meeting next quarter, and best practices will be replicated in other CHASS-supported provinces.

CHASS’ Economic Strengthening Officers will participate in a National Forum for Savings and Loans Group being organized by FARE (Fundo de Apoio e Reabilitação Económica), under the guidance of the Ministry of Economy and Finance, that promotes annual meetings of savings groups.

CHASS is collaborating with the ASPIRES project at FHI 360 in North Carolina who has been contracted by USAID to conduct a study of VSL groups and retention. CHASS is providing the necessary information required for the design of this retrospective cohort study that will assess the relationship between VSL participation and retention in HIV care.

Community Counseling and Testing Intensive efforts continued to shift the community testing approach away from mass campaigns and a “family-centered” approach, to a more focused approach targeting the sexual partners of index clients— through sexual/social network testing—as well as their younger children. OVC and their parents are also key target groups, as are key populations, in coordination with the PASSOS project. After testing, counselors continue to visit HIV-positive patients until they enter into care and treatment. Community lay counselors have all been trained and certified, but continue to need mentoring in the proper application of the index case approach.

Performance in C-HTC leveled off this quarter (Figure 19), although it increased in Tete because five districts (i.e., Chifunde, Chiuta, Magoe, Moatize, Zumbu) were not reported last quarter due to poor data quality. In this quarter, the strategy of focusing on the index case approach has been implemented by all CBOs in all provinces. In order to maximize this resource, CBOs are continuing to implement a system for tracking performance of individual counselors, allowing CBOs to focus their capacity building efforts more efficiently on the individual counselors, where it might make the most difference. Counselors have also been given a target of four patients per day, or 80 per month on average. They have also been asked to work flexible hours depending on the case, as some patients can only be found at home after working hours or on weekends. In fact, productivity varies with the context, as distance to the homes of index cases is variable and it can also be time consuming to identify the actual house of the index case, while protecting the patient’s confidentiality. CHASS has increased subsidies in order to recruit and retain capable counselors who have the communication and testing skills as well as the capacity to fill out multiple forms with somewhat complex desegregations. Continual TA is necessary so that all counselors can fill in the C-HTC forms properly. 58 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Figure 19. Number tested over time through C-HTC, by province and quarter, life of project

This quarter, 6,813 people were tested through index case 53% of all people tested via index case testing (which includes sexual network testing to the extent testing were female. possible), and 8,528 were tested through other C-HTC.7 Yield was 23 percent in index case testing and 12 percent in other 48% of all people tested via index case C-HTC. This was similar to last quarter, when yield in index testing were children under 15 years. case testing was 24 percent and that in other C-HTC was 10 percent. Yield in index case testing varied by group, with 36 percent of partners testing positive and 9 percent of children of index cases testing positive. Among partners, this was lower than expected, likely because of some misclassification of people tested as partners of index cases when they were not. This may also have been the result of index cases identifying only their most formal partner, even if this was not a person with whom they had frequent sex. Overall, 195 more PLHIV were identified via index case testing this quarter, with total number of cases identified increasing from 1,371 to 1,566.

Variation by geographic area Coverage of new patients with household visits varied dramatically by province, ranging from 5 percent in Sofala to 61 percent in Niassa. In part this appeared to be related to the number of new enrollees, as Niassa and Tete, where coverage was highest, also had a smaller number of new enrollees. This was also due to lack of full implementation of this strategy as discussed above, and it is something that will receive focused attention in Q3.

In terms of index case testing, results varied by district, although the positivity rate continued to increase in most districts. Dondo, in Sofala Province, reached a rate of 50 percent positivity this quarter. They attributed this high rate to performance monitoring of individual counselors, which first started in this district and has been very successful in focusing TA efforts; setting targets for each counselor; and intensive monitoring on a daily, weekly, and monthly basis. The individual monitoring tool has evolved to one that now has colors to indicate a low, adequate, or high number of tests carried out in relation to

7 Other C-HTC includes testing of key populations, testing during health fairs or other special events and people who are tested during the course of index case testing but who are not partners or children of the index case. 59 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

targets. The tool continues to monitor positivity rate as well as proportion of patients tested arriving in care and treatment.

Yield should continue to increase as CHASS continually carries out “Testing Workshops” where CHASS staff help counselors to improve testing and counseling techniques, by modeling and simulating effective communication approaches and reviewing data collection forms.

In terms of index case testing, only one partner was tested in the community for every six adults newly initiating on ART.8 In Niassa, this ratio was one to four and in Tete, it was one to eight (Table 14). These data should be interpreted with caution as there are a number of unknowns. We are not able at this time to capture data related to 1) the percentage of index cases whose partners’ status is known (do not need testing) and 2) the percentage of newly diagnosed patients whose partners opt for index case testing via C-HTC versus facility-based testing. The MISAU system does not capture the number of partners who are invited and arrive in a HF for testing (passive notification). Although at least some partners are coming to HFs and are being tested, and counselors are correctly probing for information on contacts and following up, this cannot be quantified. Only in the ANC unit is this being recorded, and this is not considered to be HF index case testing, as this was an ongoing activity before index case testing was introduced.

Table 14. Estimated coverage of index case testing by province, FY17 Q2 % of newly diagnosed # newly initiating on # partners tested # newly enrolled who initiated ART ART patients per partner tested Manica 83% 7,872 1,244 6 Niassa 65% 1,692 377 4 Sofala 80% 7,798 1,376 6 Tete 79% 4,046 528 8 CHASS 79% 21,408 3,525 6

Yield among partners of index cases (something we anticipate will not vary by province when this strategy is fully optimized) was highest in Niassa at 48 percent and lowest in Tete at just 21 percent (Table 15). At 48 percent, Niassa was almost in line with the expected level of 55 percent seen in other countries. Although both Manica and Sofala are slightly behind with yield in the mid 30s, we believe this will improve with more focus on the quality of testing and counseling techniques as well as improved data quality, all of which are being promoted through testing workshops. Clearly the low yield in Tete is a problem that needs to be addressed and will receive immediate attention from CHASS. Notably, the yield among partners changed from Q1 to Q2 at the provincial level. It increased in Manica and Niassa, as counselors in those provinces did a better job of classifying people tested as to whether or not they were partners of an index case. In Sofala, where yield declined from Q1 to Q2, this was because testing was reported more accurately in Q2; in Q1, some counselors were only recording positive tests because of a misunderstanding in the use of the registers and summaries. Another factor is that CHASS lost counselors due to competitive subsidies among various CBOs hiring lay staff. CHASS raised subsidies overall, in the last quarter, in order to recruit and retain capable counselors. CHASS is working to understand the reason for the low performance in Tete and it may be in part due to some lack of clarity about index case testing.

8 This is used as a proxy for new diagnoses as age disaggregated data on positivity are not available at all sites. 60 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Once the reasons are better understood, CHASS will address this through testing workshops and performance monitoring.

Table 15. Positivity rate in index case testing by group and province, FY17 Q2 Q1 Q2 Male Female Male Female partners partners Children partners partners Children Manica 15% 13% 3% 38% 35% 7% Niassa 32% 30% 9% 45% 50% 11% Sofala 64% 69% 35% 38% 37% 15% Tete 27% 58% 8% 16% 26% 2%

As discussed with USAID, CHASS is concerned that yield in C-HTC may decrease as a result of synergies with the COVida project, which aims to increase the percentage of OVC who know their HIV status. CHASS, on the other hand, has a more focused approach, aiming to test those most likely to be positive in order to increase yield. Preliminary analysis suggests that, in fact, yield among children tested as a result of a referral from COVida was lower than among the general population of children tested by CHASS. This was a crude analysis and can only be said to be indicative of what may be happening. Further analysis is needed to more clearly delineate whether or not these synergies between projects are affecting yield in CHASS C-HTC. What the preliminary analysis showed is that at sites with the strongest synergies, coverage of children was higher (55 percent of all people tested through community index case testing were children in the synergies sites versus 45 in the non-synergies sites), and yield among children in index case testing was lower (3 percent in synergies sites versus 11 percent in non-synergies sites). Even when we removed sites in Tete, which has generally lower positivity than other provinces in index case testing, yield in the synergies sites remained at 3 percent. An analysis of the positivity among children with a referral from COVida at two sites in Tete showed that just 1 percent of these children tested positive— another indication that these children may be less likely to be positive. CHASS and COVida will continue to explore this with a more rigorous methodology in Q3.

Cultural and religious influences on retention in Manica: CHASS staff reported that they are noticing a number of PLHIV requesting re-testing on Mondays after having participated in religious ceremonies alleged to cure AIDS. On further investigation, they discovered that some churches are requiring PLHIV to publicly burn their ARV drugs as a demonstration of faith in miracle water that they must purchase. CHASS generally addresses harmful cultural beliefs and practices within its social communication strategy: radio programming, community dialogue, and health education sessions involving community leaders. However, many churches do not attend health education sessions where community leaders, (especially political leaders) are present, for fear of sanction.

61 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

CHASS has addressed this question in several ways. Leveraging ties with the National AIDS Council, the Provincial CHASS CBO Membership in National Networks Department of Health, and the provincial government, a letter was sent to the Provincial Department of Justice CNCS (Religious Affairs Section), denouncing this practice as being National AIDS Council 100% counter to religious and human principles. A series of three MONASO Mozambique AIDS Association 83% radio debates on the subject were broadcast discussing the RENSIDA important moral and spiritual role the church plays in the National Network of PLHIV 42% lives of PLHIV, their families, and the community in promoting adherence to ART. They appealed to PLHIV on ART to not stop taking their ART based on incorrect advice, but to trust their health care providers' advice.

Next quarter CHASS is supporting a rapid assessment of pastors’ knowledge, attitudes, and practices as they relate to retention of patients on ART in Manica. This assessment will be carried out by the Christian Network against HIV/AIDS and the Mozambican Network of Religious Leaders Living with or Personally Affected by HIV and AIDS (MONERELA+), which is a branch of the Africa Network of Religious Leaders Living with HIV (ANERELA) started in Uganda. This will be followed by a pastors' conference involving all CHASS-supported provinces, with the aim of changing behaviors that have a negative impact on the population. The founder of ANERELA is a well-known Ugandan pastor, Reverend Gideon Byamugisha, who has vast experience in effectively organizing religious leaders’ conferences to rally their support for HIV/AIDS interventions, especially in fighting stigma, and he will also participate.

CHASS also trained traditional healers in Manica, Tete, and Niassa to refer people with HIV symptoms for testing (at either the community or HF level) and continue to support adherence once they start treatment. We believe that this is an important approach to balance messages received through religious leaders, as trained traditional healers are considered an important and reliable source of health information in many communities.

Challenges Related to Community Activities  Maximizing productivity in home visits with phone “visits.” Positive results found in busca telefonica (below) should be applied to home visits. Lay staff need practice in effective phone communication (e.g., reminders to go to the HF for care and treatment for those newly diagnosed, phone “visits,” phone “buscas”) for effective use of this tool. Phone communication must be confidential, succinct, and clear as well as assertive.  Maximizing C-HTC productivity with more focused testing. Workshops for testing and counseling demonstrate and reinforce effective practices, including the difficult areas of probing for contact information of sexual partners during counseling sessions, helping someone disclose his or her sexual partner, and communicating with a patient whose contact wishes to remain anonymous. Use of monitoring forms as well as logistics management forms to avoid stock-outs are reviewed as well. Even so, community personnel have trouble adapting to change and often confuse versions or misinterpret instructions and misclassify data affecting its quality.  Addressing cultural norms and practices that negatively affect retention.

62 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Key Community Activities in the Next Quarter  Workshops for community counselors to improve testing and counseling, data registration, and stock management skills to continue at the provincial level.  Integrated TA visits to improve efficiencies in health centers (clarifying the flow and role of the clinical and lay staff) and the technical capacity of activistas to carry out visits and buscas.  Rapid assessment of pastors’ knowledge, attitudes, and practices in Manica, to be followed by a pastors' conference.

63 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

IR3: STRENGTHENED REFERRAL/LINKAGE SYSTEMS BETWEEN COMMUNITY AND FACILITY-BASED SERVICES

Effective systems for referrals and linkages between communities and HFs are essential for maximum ART initiation, retention, and adherence to treatment. Activities implemented by the CHASS project under IR3 aim to strengthen these systems. During the quarter, several interventions were implemented.

Facilitated Linkages between C-HTC and HF Care and Treatment CHASS continued to support CBOs to ensure that community counselors facilitate linkage of HIV-positive individuals to care and treatment immediately after testing positive. Community counselors must visit consenting patients until they are linked to health services and continue to visit until they actually initiate treatment. Each province developed registers (livro pautado) for 1) HFs to follow positive patients through to care and treatment and 2) community counselors to follow positive patients through to care and treatment. The results (effectiveness of various tools) will then be shared in order to establish best practices within the project.

CHASS continued to facilitate deployment of a “circulating community case manager" in high-volume HFs to physically escort patients within HFs. This strategy of using circulating community case managers was adopted because the other case managers are placed in fixed sites, and may find it difficult to leave if they are involved in health education sessions, organization of charts, or other sectoral activities.

Last quarter, CHASS PDSA cycles showed that all sites that engaged circulating case managers showed a significantly higher proportion of patients testing positive in the health facility, enrolled in care and initiated on treatment. This quarter CHASS teams began to strengthen operational aspects of this activity such as; using mobile messaging and calls to more proactively coordinate escort activities.

Referrals CHASS continued to promote and support referrals between communities and facilities and among various community services (i.e., intra-community referrals) to ensure that PLHIV receive services that they require. Systems are reinforced during TA visits.

Again this quarter, the most common reason for referral was busca consentida (13,053 patients referred, up from 6,340 in FY16 Q4) (Table 16). However, referrals for MCH services (3,498) outpaced those for HTC (3,123) this quarter—a change from Q4. For all services except HTC, the number of referrals in Q2 was greater than in Q1. This quarter, 1,884 patients were referred by activistas for index case testing (this is in addition to patients referred from facilities to the community, discusssed below)—an increase of more than 1,000 patients relative to last quarter. Relative to the number of people who were referred to facilities by activistas, a large number of patients arrived at the HF for services, which is encouraging and means that activistas are communicating effectively and following up with patients who are referred. When calculated as a percentage, this ranged from a low of 82 percent for busca consentida to a high of more than 100 percent for GBV and other HIV services. In fact, these percentages are a bit misleading, as patients referred in one reporting period may return in a subsequent period. At the same time, this may be a data quality issue and will be reviewed as part of data quality visits to CBOs in Q3.

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Table 16. Referrals reported for HF services—referrals made and patient-referrals received, FY17 Q2 Facility Services Other MCH HTC Index Case Busca TB GBV Referrals made HIV # of sites reporting 118 117 22 145 73 104 31 referrals made by CBOs to health facilities 3,838 4,028 506 13,053 1,445 1,797 127 Patients received at health facilities 3,505 3,247 NA 10,762 1,458 1,591 136

In terms of community services, almost 693 patients were referred to CHASS-supported community index case testing services from the 27 HFs reporting these data. This was far less than the 3,600 reported in Q1, but we believe this was a reporting issue in both quarters, with over-reporting in Q1 and under- reporting in Q2. During provincial visits, the community systems team and M&E team noted that many referrals were being made and not documented by the case managers who are responsible for this. CHASS is currently working to improve the referral system and documentation for index case testing.

In Q2, 196 patients were reported to have been referred to VSL in the community (from 12 sites reporting), and 301 patients were referred to OVC services in the community (from nine sites reporting). Among those referred to community services, the majority were adults (80 percent), and 61 percent were female. Given that 70 percent of those currently on ART are women, this suggests that the community care managers in HF are prioritizing men for referrals, which is positive considering that retention of men and their involvement presents added challenges. Community partners also reported that 97 patients arrived at VSL and that 191 arrived at support groups based on a referral. This reflects intensive efforts to target those who might benefit from membership in VSL or support groups, rather than recruitment during general health education sessions, in order to increase retention through these interventions.

CHASS CBO activistas also referred patients to other FHI 360 projects. This quarter, 90 patients were referred to the PASSOS project, 160 to COVida, 74 to Challenge TB, and 17 to Youth Power. At the same time, we believe there are many more referrals occurring informally than are being recorded, using the Guia de Referencia as evidence. There will be a specific focus next quarter on improving referrals and linkages between projects to better leverage potential synergies. In addition, as progress is made in reporting of required indicators by CBOs (C-HTC and busca consentida), the M&E team will focus its support to CBOs on these additional indicators.

Defaulter Tracing CHASS continued to facilitate community staff (i.e., CBOs) to ensure that PLHIV who needed services but were not coming to facilities were traced, counseled, encouraged, and enabled to get the available care services they need. Target groups included patients who had defaulted from or abandoned pre-ART or ART services, parents or guardians of infants whose PCR test results had arrived at the facility but who had not yet been informed (including positive results and rejected specimens that needed to be re- collected), and patients who had been diagnosed as HIV-positive and were eligible for ART but had not yet started on ART. CHASS also supported searches for women who had taken post-exposure prophylaxis and who had not returned for their follow-up visits.

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A total of 20,000 patients were listed for busca consentida this quarter. The vast majority (91 percent) had defaulted from 66% of all people listed for Busca ART, but 8 percent had defaulted from PMTCT and 1 percent consentida were female. from TB/HIV care. Twenty percent of all patients were searched for via busca telefonica (a phone call), with the 10% of all patients listed for Busca remainder searched through a household visit. Almost all consentida were children under 15 years of age. patients listed were actively sought (>99 percent), 73 percent of them were found, and 69 percent returned to care. Patients who had abandoned care and men were least likely to be located (Table 17), whereas TB/HIV co-infected patients and children were most likely to be found. Patients who had abandoned care were also less likely to be returned to care among those who were found, resulting in just 58 percent of patients who had abandoned care returning compared with 72 percent of defaulters. Men were more likely to return to care if found, but because a lower percentage of men were found, they were less likely to be returned to care on the whole.

Table 17. Results of busca consentida by group, FY17 Q2 % % returned Group % sought % found returned of those found Male 100% 70% 66% 94% Female 97% 76% 68% 90% Child 95% 77% 69% 89% Adult 97% 75% 66% 88% Defaulter 97% 80% 72% 91% Abandoned 97% 69% 58% 84% TARV 97% 75% 66% 88% PMTCT 93% 76% 67% 89% TB 100% 78% 63% 81% Total 97% 75% 66% 88% * Color coding shows the ranking of each group in terms of a given result.

Among patients who were not found, 35 percent had an incorrect address, 17 percent had moved, 10 percent had died, 19 percent had travelled, and 19 percent were not located for other reasons.

Busca consentida was most effective in Niassa and Tete, where 77 percent of all patients listed were returned to care (Figure 20), despite the fact that both of these provinces had larger percentages of patients listed who had abandoned care (69 percent in Niassa and 59 percent in Tete compared with less than 42 percent in Sofala and Manica). A smaller percentage of patients in Niassa (91 percent) returned to care if they were found, but more patients were found there (77 percent). Busca consentida was least effective in Manica, where 70 percent of all patients listed were returned to care, largely because only 69 percent were found.

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Figure 20. Busca cascade per province, FY17 Q2

Seventy-eight percent of patients who were sought via busca telefonica returned to care, compared with 71 percent of those sought through household visits. This result was somewhat misleading, as patients who were not reached by phone were referred for household visits, meaning that they were by definition harder to reach.

Challenges Related to Community-Facility Linkages  Maximizing productivity in defaulter tracing, referrals, and linkages. Ensuring that data systems, flow of information, and technical interventions are effectively carried out with rigor and efficiency.  Maximizing synergies between FHI 360 projects to support access, adherence, and retention in care.

Key Community-Facility Linkages Activities in the Next Quarter  Integrated TA visits to improve efficiencies in health center (clarifying the flow and role of the clinical and lay staff) and technical capacity of activistas to carry out visits and buscas.  Synergies workshops with various FHI 360 projects to perfect community-HF and intra- community referral systems and improve documentation on these linkages.

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STRATEGIC INFORMATION

Electronic Patient Tracking System In Q2, retrospective data entry was completed at eight new sites,9 and five of these sites were handed over to the relevant DPS while the remaining three are in the process of being handed over. Thus, CHASS now has a total of 36 sites reporting with the EPTS (Figure 21), and we are on track to meet the targets for 2017.

9 Ponta Gea and Chamba in Sofala, Macate and Gondola Sede in Manica, Chitima, Songo and Ulónguè Rural Hospital in Tete, and Mecanhelas in Niassa. 68 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Figure 21. Map of EPTS sites by year of handover

In Sofala, the team completed the server implementation, and all EPTS databases were migrated to DPS. This will support the growth of the EPTS database as the team prepares for the expansion to additional districts. We expect this process also to encourage data use at the DPS level since every HF database can now be accessed in-house. The same process is ongoing in Manica and Tete. Because all data entry must cease during the migration and the equipment was not available in the provinces until the end of the quarter, this was delayed to Q3.

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During Q2, some HFs received new computers (11) and printers (29) to cope with the growth of the volume of daily visits and to encourage the HFs to use the system to generate regular reports that can support their decision-making process.

Implementation in Sofala is a particular challenge due to the high volume of patients at each HF there. Although we anticipate that this will become less of a problem as we move out of Beira City, during preparation visits to Dondo it became clear that the volume of patients eligible (all past and current patients) to be entered into the EPTS is almost double our initial estimate. For example, in Dondo Sede, our initial estimate was 4,600 patients, but there are an estimated 9,300 patients to be entered. Likewise, in Mafambisse, the estimate has increased from 3,600 to 7,800 and in Nhamatanda Sede, from 4,400 to 10,400 patients. CHASS is exploring alternative strategies to approach these HFs, but this change will increase the time required for implementation at each HF and may therefore affect the total number of EPTS sites at the end of the year in Sofala.

In FY17, in addition to EPTS expansion, CHASS is focused on ensuring and improving the quality of the data in the system. The team visited all provinces during Q2 to conduct initial evaluations of data quality and completeness based on a standard operating procedure developed in late Q1. Initial results were encouraging, as all the sites scored above 80 percent of data conformity, with some of them scoring very close to or higher than 90 percent. These reviews highlighted some common challenges, including changes in WHO staging, missing dates of events, and CD4 results that are available in the chart but not recorded on the follow-up form (which is the source for comparison). Some of these issues were corrected immediately by the field team, others were flagged and the team instructed on how to correct and avoid them in the future, and others were shared with the HFs with recommendations on how to address them. During Q3, we will continue to visit other HFs to perform the same assessment and follow up on the recommendations.

A common issue in all provinces is the delay in updating the latest visits in the system. This is partially due to the lack of human resources at HF to operate the system. During discussions with DPS Sofala, the DPS confirmed that there are huge restrictions on human resources on their side and that it will be extremely difficult for them to address this issue by themselves. They requested that CHASS provide support to fill the gaps where needed. In Q3, CHASS will post full-time data entry clerks to HFs that have been handed over. These staff will ensure that EPTS databases are updated in a timely fashion, and will develop the capacity of HF staff for data entry and data use through on-the-job training. CHASS continues to support HF and DPS ownership of the system, and this approach has the potential to undermine that. However, not having current data will also undermine use of and confidence in the system.

In addition to the CHASS implementation, in Q2 the CHASS EPTS team continued to collaborate with the UCSF team to test and debug the queries developed for reporting. The team is also working with UCSF to expedite the development of the pharmacy module (drugs dispensation only, for now) within OpenMRS. CHASS will work with UCSF on testing the module, sharing insights on HFs' work flows, and developing implementation and training plans. In addition to ensuring accurate reporting by CHASS, this is an important contribution to the national system.

Optical Character Recognition Pilot CHASS is collaborating with MStar to conduct a pilot of optical character recognition software. The pilot will test the use of hand scanners for collecting and aggregating counseling and testing data (the PEPFAR

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required disaggregations) as well as collecting data from monthly summaries. This quarter, CHASS worked with MStar to finalize the plans for the pilot and met with Maraxis (the organization that will lead the pilot in Mozambique) to develop an operational plan for the pilot. A tool for recording time spent on data collection was developed by Maraxis, and CHASS M&E staff in Manica began using it to track their time during manual data collection. Training in use of the optical character recognition technology will take place in mid-April with preliminary results available in Q3.

Internal M&E Strengthening CHASS held a quarterly M&E meeting for all provincial M&E advisors, managers, and officers in Tete from February 13-17. The meeting included presentations and discussions on key M&E processes and procedures, field visits to work in cross-province teams and share best practices, and discussions of human resources issues and strategies. Outcomes of this meeting included revisions to our internal DHIS- 2 database to facilitate use by M&E and technical teams; the identification of additional tools/standard operating procedures needed (which are now under development); strengthened management of the M&E team through improved compliance with terms of reference for each position and improved mechanisms for accountability; more focus on monthly statistical validation meetings and the development of a standard terms of reference for these meetings in each province; and the addition of CHASS staff at all EPTS sites.

The central team conducted visits to all provinces this quarter, with two visits to Tete. The visits used a standard approach and included validation of the EPTS at select sites, data verification and improvement of key indicators at selected HFs and CBOs, and review of M&E systems at CBOs and in provincial offices. In general, the results of the data verification and improvement at HFs showed reasonable levels of consistency between original source data and results reported in monthly summaries, in SIS-MA, and to PEPFAR. However, some sites had greater inconsistencies than others (particularly Lichinga CS and Eduardo Mondlane), and some indicators were more problematic (e.g., PCR). Direct feedback has been given to individual sites and the CHASS team has worked with sites to update data based on these reviews, but other issues require broader action. In particular, the need for greater participation in monthly district statistic meetings is being addressed, as described above. Challenges and solutions related to community data and the EPTS are discussed in the relevant sections above.

Meetings with each DPS were a key component of these visits and were an opportunity to discuss and further harmonize M&E activities. The meeting were beneficial as factors affecting timely data submission in SISMA and possible solutions were discussed and next steps were defined. Regarding EPTS, challenges to DPS ownership were discussed and actions have been outlined in order to improve the use of the EPTS at both HFs and DPS. Stock management for M&E tools was also discussed and issues were addressed to avoid stock outs.

Community data systems Again this quarter, the CHASS M&E team collaborated with the Community Systems team to strengthen community data, particularly for the PEPFAR community indicators (ATSC, including CI testing, and busca consentida). We introduced separate registers for Index Case and non-Index case testing to facilitate the separation of these data. The registers are identical but the covers note which service they are for and the summary tools are specific to a register which reduces the changes of mis-reporting data.

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Community data was one focus during the site visits by the central teams this quarter. We conducted reviews of data systems at CBO level as well as in health facilities and we verified key indicators at some CBOs. The results show varying levels of capacity at different CBOs with some quite strong in terms of organization of data and others weak. Provincial teams were given specific guidance on followup with these CBOs and the central team is currently adapting some tools (the Busca Database for example) to provide the CBOs with more information on data quality before they report so that they can review prior to submission.

During provincial visits, the CHASS provincial M&E teams participated in the M&E data review processes that was led by the Central team but included the provincial team and the CBOs. This helped to clarify the need for and type of TA needed by CBOs. The CHASS Community Systems and M&E teams are working to ensure that zonal teams include review and TA for community activities, including M&E during all HF visits. Provincial teams also began holding monthly CBO data review meetings to review and discuss data quality.

Data use In 2017, CHASS will strengthen work on data use with both CHASS staff and health system staff at all levels from the HFs to the provincial teams. As noted in our last report, CHASS issued a request for proposals for a consultant to work with the project to rapidly develop a PowerBI platform for use by the project. CHASS decided not to award the consultancy but instead to work with the FHI 360 HQ IT team on this initiative. An IT expert, Noah Evans, worked with the CHASS team during the M&E meeting in Tete and has drafted a first dashboard. However, the first draft is quite preliminary as his visit identified a number of improvements needed in our DHIS-2 instance to facilitate the kind of data use in the future. These issues were resolved following the visit and have improved functioning of the system.

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PROJECT MANAGEMENT AND IMPLEMENTATION In addition, in response to the poor quality of the reports received from the SDSMASs in previous quarters, the Programs team also provided TA to the provincial teams and each SDSMAS to improve the quality of these reports using new templates provided by CHASS.

Sub-agreement management with DPS During Q2, the Programs team at the central level organized TA to the Program Teams in the four provinces. The main aim of these visits was to support the provincial teams to address HF needs that will be covered by the DPS in-kind sub-agreement. The teams visited DPS, districts and HFs to help identify the needs and clarify the funding mechanism and its requirements. The central team worked with the CHASS provincial teams to submit the requests to procurement. The results of this are expected to be seen in Q3 when the resulting purchases have been made.

Responsibility for identifying needs has now been transferred to the zonal teams given that they are in daily contact with health facilities and are better aware of needs. They will forward requests to the provincial programs teams for processing. This will help ensure that all HFs use their planned budgets in Y2.

CHASS also provided support for improved quality and timeliness of reporting by DPS to improve disbursement of funds through the fixed price sub-agreements. Disbursements were almost four times greater in Q2 than Q1 (Table 18). The increase is also due to the fact that payments for in-service training are made at the beginning of the calendar year (Q2).

Table 18. Funds disbursed to DPS, FY17 Balance Y1 Q1 Y2 Q2 Y2 Province In-Kind Fixed price In-Kind Fixed Price In-Kind Fixed Price Total Q I Q I Q II Q II Manica 21,680,149 10,634,085 1,363,368 212,000 7,865,227 4,305,000 46,059,829 Sofala 34,764,718 3,997,714 10,937,049 4,035,936 8,921,914 596,744 63,254,075 Tete 41,983,243 10,078,120 9,771,181 191,278 4,133,940 3,187,532 69,345,295 Niassa 14,747,517 10,244,865 569,216 132,872 2,008,877 8,818,872 36,522,219 TOTAL 113,175,627 34,954,784 22,640,814 4,572,086 22,929,958 16,908,148 215,181,417

Sub-agreement Management with SDSMAS During Q2, CHASS held meetings with districts directors in some districts to discuss the quality of the reports submitted as well as to explain to them that some funds were decreased due to the poor quality of the reports. To avoid this situation in the future, the Program team at the central level developed templates for the different reports to be submitted at the end of each he quarter and shared them with the provincial teams. A particular challenge is documentation of data review meetings; CHASS is working to ensure that all reports clearly show the key data an performance issues identified in these meetings as well as decisions made to address them. The results can already be seen in the increased level of expenditure in Q2 (Table 19) although this was also the result of the ability to visit all districts with the cease fire in place.

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Table 19. Funds Disbursed with SDSMAS, FY17 Province Q1 Q2 Total Manica 330,510 10,514,634 10,845,144 Niassa 132,872 7,445,489 7,578,361 Sofala 10,566,948 5,853,851 16,420,799 Tete 397,802 9,789,849 10,187,651 TOTAL 11,428,132 33,603,823 45,031,955

Sub-agreement Management with CBOs This quarter, CHASS’s support to CBOs focused on Modifications needed in order to accommodate the full time staff needed at HFs and in communities (e.g., counselors) as well as to include other necessary activities that will benefit the people served by the project. Subsidies of all Case Managers were adjusted to reflect their workload as were those of counselors, activistas and VSL group facilitators leading to an increase in disbursements (Table 20). The Program team also supported the community team to verify the lists of staff in the field to ensure that all people paid by CBOs are implementing activities.

Table 20. Funds Disbursed to CBOs, FY17 Province Q1 Q2 Total Manica 3,884,498 8,028,087 11,912,585 Niassa 3,430,032 3,015,627 6,445,660 Sofala 33,384,598 43,236,650 76,621,248 Tete 2,910,064 2,411,618 5,321,682 TOTAL 43,609,193 56,691,982 100,301,175

Technical Assistance The objective of the TA activities is to ensure that high quality HIV services are offered by public sector facilities and to support community partners to perform their activities according to their workplans and following rules and regulations of the donor. In Q2, with better documentation of visits and a cease fire in districts that were previously inaccessible, CHASS teams were able to conduct more TA visits and provided TA in more sites (Table 21). Overall, over 100 percent of planned TA visits were accomplished this quarter compared to just 65 percent in Q1.

Table 21. Number of planned and completed TA visits by province and quarter, FY17 Q1 Q2 Province Planned Done % Complete Planned Done % Complete Manica 378 150 40% 300 303 101% Niassa 83 54 65% 84 77 92% Sofala 701 479 68% 967 991 102% Tete 175 188 107% 179 187 104% T O T A L 1,337 871 65% 1530 1558 102%

Capacity Building for CBOs The CHASS project aims to strengthen the capacity of CBOs, increasing the competencies (knowledge, skills and attitudes) in the areas of Associations, Governance, Leadership and Management, Internal Control Systems, and Policies and Procedures as well as in design and project management. CHASS works 74 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

with the executives and staff of the 12 CBOs (3 in Manica, 2 in Niassa, 4 in Sofala, and 2 in Tete). This quarter CHASS prioritized Sofala Province with the main objective of ensuring the capacity of the CBOs there so that they can act as a model for other CBOs. The following activities were carried out in Q2:

 Training of 67 people in Governance Association (22 members of CBO boards, 23 simple members and(22 CBO staff)

 13 TSV to the CBOs Kuphedzana, Ajulsid, Kugarissica and CCM with the objective of:  Elaborating a code of conduct;  Instituting procedures for risk reduction  Ensuring clear systems for Internal control

Challenges related to Programs  With requisitions in process to address HF needs, ensuring the operationalization of these requisitions will be a challenge in the next quarter.

 New needs arise at HF on an ongoing basis, these will need to be addressed moving forward but the transition of responsibility to the zonal teams aims to address this.

Key Programs activities for the next quarter  The programs team will work with the finance and procurement teams to ensure that the requisitions are completed and that supplies and equipment are delivered and renovations completed  The Programs team will work in greater collaboration with zonal teams (including clinical and M&E staff) to identify HF needs and ensure they are rapidly shared with the Program officers  Meet with HFs that did not benefit from TA in Q2 and continue to need support to understand and work with the funding

Security and site accessibility Because the ceasefire agreed between RENAMO and the Government of Mozambique in late 2016 has been extended, CHASS was able to provide TA and to collect data in all district this quarter; the first time since the project was expanded to Manica, Sofala and Tete. Some sites continue to be affected in that they were closed during the political turmoil. These sites are scheduled to re-open in Q3. While political instability did not affect TA or data collection in Q2, 28 sites were not accessible due to flooding from seasonal rains (Annex 1).

Overall, 370 of 395 (94 percent) of CHASS-supported sites were visited for data collection (Figure 22), which is a key measure of accessibility given that not all sites are required to have a TA visit during the quarter. Due to the cease fire, many more sites were accessible than at any time since the merging of CHASS Niassa and CHASS SMT. However, seasonal flooding prevented access to some sites this quarter. Overall, coverage of the 182 DSD sites was 94 percent (Table 22), while that for 48 TA sites was 96 percent. At the provincial level, although 98 percent of CHASS-supported sites in Niassa were visited, only 93 percent of the sites in Manica and Sofala were visited.

75 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Figure 22. Site accessibility by support type, FY17 Q2

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Table 22. Coverage of sites for data collection by province and support type, FY17 Q2 Support type Sim Total Not % visited CHASS DSD 182 194 12 94% TA 48 50 2 96% Other 140 151 11 93% ALL 370 395 25 94%

Manica DSD 68 73 5 93% TA 3 3 0 100% Other 27 29 2 93% ALL 98 105 7 93% Niassa DSD 17 17 0 100% TA 13 13 0 100% Other 52 53 1 98% ALL 82 83 1 99% Sofala DSD 59 63 4 94% TA 10 12 2 83% Other 28 33 5 85% ALL 97 108 11 90% Tete DSD 38 41 3 93% TA 22 22 0 100% Other 37 40 3 93% ALL 94 99 5 95%

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MAJOR PRIORITIES/ACTIVITIES PLANNED FOR NEXT QUARTER  Transition providers in Q2 QI HFs to a more focused approach to PICT.  Expand ROOT to additional sites in order to improve coverage of all eligible children  Support the rollout of T&S in the 11 new sites in Phase II, building on lessons learned from Phase I.  Introduce additional counselors (e.g., Gestores de Casos and Mentor Mothers) to expand the availability of adherence counseling and reduce waiting time for this service.  Strengthen operationalization of viral load testing by ensuring that clinical staff request it for all eligible patients.  Support the installation of the DISA Link program in the laboratory at the Provincial Hospital in Lichinga for the management of samples and results.  Strengthen procedures to ensure that lab results reach clinicians.  Intensify support for roll out of the three-month dispensing initiative in existing HFs and provide technical support for the expansion plans for new sites.  Train additional cadres (e.g., Community case managers and Mentor Mothers) to provide psychosocial support and positive prevention to improve retention among pregnant women.  Collaborate with Challenge TB to strengthen referrals of suspected cases from the community to HFs.  Reintroduce the TB screening tool in ART consultations to ensure more complete and accurate screening of HIV-positive patients.  Strengthen the technical capacity of health providers to implement the NRP integrated in care and treatment of PLHIV using the QI strategy in accordance with the directives issued by MISAU.  Reinforce TA in drought-affected sites for clinical care and documentation of services provided.  Provide evidence-based guidance to CHASS provincial teams on effective strategies for engaging male partners; advocating for men-friendly services at the Super 16 sites; facilitating monthly community meetings with influential male leaders; and targeting male-dominated workplaces with comprehensive messages and services on HIV/AIDS.  Strengthen community partners capacity to build awareness of and address gender norms that affect HIV, to support male involvement, and provide support for victims of GBV in communities.  Support MISAU in training, disseminating, and operationalizing the new GBV instruments.  Roll out the training package for the second cycle of the MISAU-led QI approach.  Hold workshops for community counselors to improve testing and counseling, data registration, and stock management skills to continue at the provincial level.  Conduct integrated TA visits to improve efficiencies in health centers (clarifying the flow and role of the clinical and lay staff) and the technical capacity of activistas to carry out visits and buscas.  Conduct rapid assessment of pastors’ knowledge, attitudes, and practices in Manica.  Synergies workshops with various FHI 360 projects to perfect community-HF and intra-community referral systems and improve documentation on these linkages.

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ANNEXES

Annex 1. Sites not accessible for data collection in FY17 Q2 due to flooding Manica / Machaze / Mavissisanga CS III Manica / Machaze / Sambassoca CS III Niassa / Mecula / Mbamba CS Sofala / Buzi / Ampara PS Sofala / Buzi / Nhamichindo PS Sofala / Chemba / Catulene PS Sofala / Cheringoma / Nhataca PS Sofala / Cidade Da Beira / Chamba PS Sofala / Dondo / Chibuabuabua PS Sofala / Machanga / Chiloane PS Sofala / Machanga / Inharingue PS Sofala / Maringue / Senga Sofala / Marromeu / Amambos CS Sofala / Marromeu / Chueza PS Sofala / Marromeu / Maringapansi PS Sofala / Muanza / Muanza - Baixa (Pedreira) PS Sofala / Nhamatanda / Mecuzi PS Sofala / Nhamatanda / Nhampoca PSA Tete / Angonia / Vila Velha PS Tete / Changara / Chiôco CS III Tete / Chiuta / Cazula Tete / Cidade De Tete / Mufa-Boroma Tete / Magoe / Mussenguezi CS Tete / Maravia / Chinhanda CS Tete / Mutarara / Ancuaze PS Tete / Mutarara / Jardim PS Tete / Tsangano / Centro de Saude de Fonte Boa Tete / Tsangano / Khanga

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Annex 2. Provincial ART cascades, FY17 Q2

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81 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Annex 3. Number of participants in CHASS commodity management training by province and type of participant Source of Participants Sofala Manica Tete Niassa Health Facilities 49 30 43 11 DPS/DPM/DDM 4 0 3 4 Total 53 30 46 15 Grand Total 144

Annex 4. Health facilities receiving commodity management training in FY17 Q2 Province Health Facilities/ Departments Manica (21) HP Chimoio, CS Ed. Mondlane, CS 1° de Maio, CS 7 de Abril, CS Nhamaonha, CS Vila Nova, HD Manica, CS Machipanda, HD Gondola, CS Sussundenga, HR Catandica, CS Macossa, CS Guro, CS Macossa, CS Nhacolo, HD Espungabera, CS Dacata, CS Chitobe, CS Save, CS Vanduzi, CS Macate Sofala (22) CS Ponta-Gêa, CS Manga Mascarenhas, CS Nhaconjo, CS Macurungo, CS Manga Loforte, CS Munhava, CS Matadouro, CS Ceramica, DDM Dondo, CS Dondo, CS Canhandula, CS Savane, HR Marromeu, CS Chupanga, CS Nensa, CS Chupanga, CS Nova Salone, CS Amambos, CS Chueza, CS Tica, CS Lamego, HR Nhamatanda Tete (7) CS1, CS2, CS3, CS4, CS Magoe, CS Moatize, DPM Tete Niassa (10) CS Mecanhelas, CS Chissua, CS Nipepe, CS Maua, CS Metarica, HR Cuamba, CS Lurio, CS Cidade de Lichinga, CS Namacula, CS Chiuaula CS= Centre de Saude, HR=Hospital Rural, HP=Hospital Provincial, HD=Hospital Distrital

Annex 5. Facilities Receiving Support for the Management of Pharmacy-based Records, FY17 Q2 Province Health Facilities Tete (09) CS 1, CS2, CS 3,CS 4, CS Mpadue, HP Tete, CS Moatize, CS Mucumbura CS Mágoe Sofala (17) CS Nhaconjo, CS Ponta-Gêa, CS Mascarenhas, CS Macurungo, CS Chamba, CS Munhava, CS Matadouro, CS Ceramica, CS Manga Loforte, CS Dondo, CS Canhandula, CS Savane RH Marromeu RH, CS Chueza, RH Nhamatanda, CS Lamego, CS Tica Manica (12) HD Manica, CS Machipanda, CS Messica, CS 1° de Maio, CS Ed. Mondlane, CS Nhamaonha, CS 7 de Abril, CS Chitobe, CS Save, CS Espungabeira, HD Catandica, CS Sussundenga Niassa (8) CS Sanga, CS Mecanhelas, CS Chissaua, CS Namacula, CS Chiuaula, CS Cidade de Lichinga, CS Cuamba, CS Lurio CS= Centre de Saude, HR=Hospital Rural, HP=Hospital Provincial, HD=Hospital Distrital

82 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

Annex 6. HF Level Management Strengthening Intervention Package

Diagnostic Tools to Measure HF Management and Interventions to Strengthen Site Management and Improve Efficiency of HIV Service Delivery Efficiency of HIV Services HF Patient Patient Patient 5S QI Clinical Files Patient Appointment Institutional Waiting Satisfaction Flow & Program Reviewed & Flow & Logbooks Assessment Times Evaluated Site Archives Sector Adopted Measured Mapping Reorganized Location Optimized

Sofala 18 7 6 4 11 9 4 7 Manica 13 3 3 2 3 3 3 3 Tete 6 6 5 5 6 6 5 4 Niassa 12 11 11 5 3 4 5 2 Q1 Total 33 13 12 1 2 1 1 1 Q2 Total 16 14 13 15 21 20 16 15 TOTAL 49 27 25 16 23 21 17 16

Annex 7. Progress Toward Strengthening District Logistics Systems, FY17 Q2 Province Logistics Matrix GIS Logistics Map District Logistics Logistics Plan Designed Available in Analysis Meeting Being (destination District with Conducted Implemented calendar, Routes Clearly (routes refined (as outlined in the distances, Defined and approved with logistics map and objectives, fuel matrix joined to matrix) estimates, costs, map) etc.) Sofala 3 4 4 4 Manica 7 7 6 5 Tete 3 3 3 3 Niassa 5 5 5 5 TOTAL 18 19 18 17

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Annex 8. In-Service Training, FY17 Q2

Sofala Manica Tete Niassa

- - - -

- - - -

Kind Kind Kind

Tot Kind

- - - Nº Training Theme -

al

Agreement Agreement Agreement Agreement

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KindSub KindSub KindSub KindSub

Agreement Agreement Agreement Agreement

ProvincialIn ProvincialIn ProvincialIn ProvincialIn

DistrictIn DistrictIn DistrictIn DistrictIn

Sub Sub Sub Sub

1 ART clinical management 108 44 35 29 HIV care and treatment in key 2 86 27 59 populations 3 Test and Start 203 175 28 4 EMTCT / Option B+ 34 34 5 Training in early infant diagnosis 60 20 17 23 TB/HIV pediatric clinical 6 48 22 26 management 7 Viral load 58 32 26 8 Quality Improvement 96 55 41 9 Nutritional Rehabilitation 51 51 10 GBV case management 34 34 11 Gender awareness raising training 30 30 Medications inventory 12 17 17 management STI/HIV/AIDS health information 13 15 15 system New MCH health information 14 60 60 system TOTAL 900 290 101 200 70 92 55 92 0

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