Zimbabwe HIV Care & Treatment Project

ANNUAL PROGRESS REPORT O C T O B E R 1, 2015 – S E P T E M B E R 30, 2016

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Zimbabwe HIV Care and Treatment (ZHCT) Project

Cooperative Agreement Number: AID-613-A-00009

Project Start and End Date: September 24, 2015 to September 24, 2020

Prepared for: Dr Ruth Bulaya-Tembo, Agreement Officer’s Representative

Submitted by: Dr Kwame Essah, Chief of Party Family Health International (FHI 360) 65 Whitwell Road, Borrowdale West, , Zimbabwe Tel: +263-8677 0042 18 Email: [email protected]

This report was prepared with funds provided by the U.S. Agency for International Development under Cooperative Agreement No. AID-613-A-00009. The contents of this report are the sole responsibility of Family Health International (FHI 360) and do not necessarily reflect the views of USAID or the United States Government.

October 1, 2015 – September, 30 2016 | Year 1 Annual Progress Report 1

TABLE OF CONTENTS

TABLE OF CONTENTS ...... 2 TABLE OF FIGURES...... 3 LIST OF TABLES...... 3 LIST OF ACRONYMS ...... 4 1. EXECUTIVE SUMMARY ...... 5 2. INTRODUCTION ...... 6 3. DETAILED ANNUAL RESULTS AND ACHIEVEMENTS ...... 8 3.1 HIV Testing Services ...... 8 3.2 Quality assurance for household index testing ...... 10 3.3 HIV testing yield...... 10 3.4 Enrolment into care ...... 12 3.5 Symptom Screening ...... 16 3.6 Defaulter Tracking ...... 17 3.7 PLHIV receiving ARVs through CARGs ...... 17 4. PERFORMANCE INDICATOR SUMMARY ...... 18 5. LABORATORY SERVICES STRENGTHENING ...... 19 6. CHALLENGES ENCOUNTERED ...... 20 7. MONITORING AND EVALUATION...... 21 8. ZHCT PROJECT COLLABORATION WITH OTHER PARTNERS ...... 22 9. FHI 360 REGIONAL AND TECHNICAL SUPPORT ...... 23 10. ADMINISTRATIVE AND OPERATIONAL ISSUES ...... 23 11. LESSONS LEARNT ...... 24 12. LOOKING AHEAD: ZHCT PRIORITIES FOR YEAR 2 ...... 25 Annex I: ZHCT Annual Progress Summary...... 27 Annex II: Year 1 Implementation Update ...... 29 Annex III: List of ZHCT SOPs and Data Collection Tools ...... 33

TABLE OF FIGURES

Figure 1: ZHCT Implementation Districts ...... 7 Figure 2: ZHCT HIV Testing Cascade ...... 8 Figure 3: HIV Positive Target versus Achievement ...... 9 Figure 4: Individuals receiving HTS by Age Category ...... 10 Figure 5: CHOs undergoing rapid HIV testing training ...... 10 Figure 6: Yield Rate by District ...... 11 Figure 7: HTC_Positives and Yield Rate by District ...... 11 Figure 8: Outreach Workers receive bicycles, phones and bags ...... 12 Figure 9: Linkage Rate by District ...... 13 Figure 10: Linkage Rate by Age Category ...... 14 Figure 11: Yield Rate by Entry Point ...... 14 Figure 12: Linkage Rate by Age Category per District ...... 15 Figure 13: ZHCT Annual HTS ...... 15 Figure 14: Yield for Sexual Partners ...... 16 Figure 15: Defaulter Tracking Cascade ...... 17

LIST OF TABLES

Table 1: TB Screening...... 16 Table 2: Annual Indicator Performance Table, Sep. 2015 - Sept. 2016 ...... 18 Table 3: Challenges and Mitigation Measures ...... 20

Cover Photos: Top left: Members of a family-based CARG; Top right: A young girl successfully returned to care; Bottom left: Members of a sex work-based CARG; Bottom right: Motorbikes used by ZHCT Project community nurses. All Photo Credits in Report: FHI 360

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LIST OF ACRONYMS

APHL Association of Public Health Laboratories APR Annual Progress Report AR&P Annual Review and Planning ART Antiretroviral Therapy ARVs Antiretroviral medicine AWP Annual Workplan CARG Community ART Refill Group CATS Community Adolescent Treatment Supporters CHO Community Health Officers COP Country Operational Plan CPF Community Program Facilitator DATIM Data for Accountability, Transparency and Impact DREAMS Determined Resilient Empowered AIDS-Free Mentored and Safe DCT Data Collection Tool DHIS2 District Health Information System version 2 DMO District Medical Officer EQA External Quality Assurance FHI 360 Family Health International 360 GOZ Government of Zimbabwe HTS HIV Testing Services LIMS Laboratory Information Management System LTFU lost to follow up MMD Multi Month Dispensing MOHCC Ministry of Health and Child Care MOU Memorandum of Understanding NMRL National Microbiology Reference Laboratory OPHID Organization for Public Health Interventions and Development OW Outreach Worker PEPFAR President’s Emergency Plan for AIDS Relief PMD Provincial Medical Director PMP Performance Monitoring Plan PLHIV Persons Living with HIV PSI Population Services International QA Quality Assurance SOP Standard Operating Procedures TBD To Be Determined TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development VL Viral Load Y1 Year One ZHCT Zimbabwe HIV Care and Treatment Project ZiLACODS Zimbabwe Laboratory Commodities Distribution System

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1. EXECUTIVE SUMMARY

This report presents the cumulative achievements, experiences, challenges and lessons learned in year one (Y1) of the five-year Zimbabwe HIV Care and Treatment (ZHCT) Project implementation covering the period September 24, 2015 to September 30, 2016. Family Health International (FHI 360) and Plan International, as sub-awardee, are implementing the project.

During the period under review, FHI 360 set up an operational structure that will effectively sustain the project for the five-year period. This ANNUAL REACH included setting up a national office in Harare and two offices in and for the Manicaland and Midlands provinces, respectively; as well as recruitment and deployment of staff. In line with Government of Zimbabwe (GOZ) policy, FHI 360 managed to sign a memorandum of 20,194 understanding (MOU) with Ministry of Health and Child Care (MOHCC) People tested and as well as 13 MOUs at sub-national level with provinces and local received their result authorities in the eight districts of ZHCT Project implementation for Y1.

Household index testing with linkage to care, defaulter identification and tracking and other direct services at community level started in March 2,101 2016. This meant that FHI 360 effectively had seven months to achieve People tested positive COP 15 targets for Year 1 of the ZHCT Project. Despite a delayed “take- off”, the project made huge progress in Q3 and Q4 which contributed for HIV significantly to the overall achievement of the following key results for the period under review: -

10% . 2,101 HIV positive clients were identified, with 927 males and 1,174 Yield rate females; . An overall yield rate of 10% was achieved (against a target of 10%) with Manicaland 9% and Midlands 13%; . 1,579 (75%) newly identified people living with HIV were linked to care 1,579 (pre-ART) with highest linkage rate achieved in Gokwe South (86%); Enrolled in care . 3,118 people living with HIV receiving antiretroviral (ARV) drugs through 383 functional CARGs; . Conducted ZHCT Project baseline assessment and mapping exercise 75% . Standard operating procedures (SOPs) and data collection tools (DCTs) were developed to guide project implementation and effectively Linkage rate track progress towards achievement of targets; . 2 laboratories in Gweru and Mutare were renovated to facilitate setting up a viral load polymerase chain reaction (PCR); 383 . Initiated the process to procure 6,600 viral load reagents to support CARGs formed and MOHCC Viral Load Scale Up; functional . 2 provincial offices for Manicaland and Midlands and 8 district offices were successfully set up and are functional; . One national level MOU with MOHCC and 13 MOU were signed with provincial and local authorities in the 8 districts where ZHCT is operating; 3,118 . One MOU signed with OPHID Trust to formalize joint collaboration on PLHIV receiving ARVs community-health facility linkages for delivery of HIV Services in the through CARGS USAID priority districts.

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2. INTRODUCTION

This report is the first Annual Progress Report (APR) for the ZHCT project. The report details the key accomplishments and results achieved between October 1, 2015 and September 30, 2016. The overarching goal of the project is to increase the availability and quality of care and treatment services for persons living with HIV (PLHIV), primarily through community-based interventions that complement the public health sector as part of the multi-sectoral response led by the Government of Zimbabwe (GOZ). The project has completed 12 out of its 60 months of implementation. The ZHCT project accomplishes this goal by meeting the following specific objectives:- 1) To increase the availability of quality comprehensive care and treatment services for HIV-positives at community level; and 2) To strengthen community-level health systems to monitor, track and retain persons living with HIV (PLHIV) in care. The ZHCT project is a comprehensive community-based intervention designed to provide sustained linkages between the community and health facilities. ZHCT will contribute towards Zimbabwe’s attainment of the first and the third 90s of the UNAIDS Strategy1 aimed at ending AIDS by 2030 through consolidating and scaling up community-based activities which are specifically targeting adolescents, young women, pregnant and breastfeeding women as well as males and their sexual partners. In Y1, ZHCT Project was implemented in eights districts across two provinces of Midlands and Manicaland and targeted communities around 129 tier 1 & 2 health facilities2. The eight districts of implementation were Buhera, Chipinge, Makoni, Mutasa, Mutare () and Gokwe South, Gweru and (). In Y2, ZHCT will not only continue activities in the eight current districts, but also expand its HIV service provision to an additional five districts in province (Chivi, Gutu, Masvingo, Mwenezi and Zaka). ZHCT implements its services in the catchment areas of tier 1 & 2 facilities.

The ZHCT project has two main components in line with the two broad objectives highlighted above. Component 1 focuses on expanding the provision of comprehensive HIV care and treatment services. During the period under review, the priority in this component of the project was community-based household index testing with linkage to care and, symptom screening including TB screening with referral. Component 2 of the project focused on improving HIV treatment support systems in the targeted communities including defaulter identification and tracking and adherence support for PLHIV through formation of CARGS. In Y1, the set targets for the project were for 20 districts3 but the project implemented in eight districts to allow for learning and expansion in subsequent years of project implementation. The implication was that the eight districts ended-up performing to accommodate the targets from the other 12 districts. The performance in the eight districts is much higher than the previously set targets as shown in the detailed annual results and achievements narrative below. In Y2, ZHCT will intensify implementing the differentiated models of HIV care and treatment in the current and additional districts to complement the GOZ’s efforts to decentralize HIV care and treatment and innovative strategies to deliver ART, e.g. task shifting.

During the course of the year, ZHCT held two quarterly provincial program and data review meetings to reflect on strategies to improve performance, particularly on yield and linkage rate. In addition, an Annual Review & Planning (AR&P) meeting was held in July 2016, bringing together ZHCT program, technical and finance and administration staff to review Y1 overall performance (September 24, 2015 to end of July 2016), strategies to achieve COP 16 targets as well as generate input to enhance overall quality of the project in Y2. Plan International, Africaid and MOHCC

1 The UNAIDS 'Fast-Track' targets for 2020 are that: (1) 90 percent of people living with HIV will know their HIV status (2) 90 percent of people diagnosed with HIV will receive antiretroviral treatment (3) 90 percent of people on treatment will have maximally suppressed viral loads. 2 These facilities serve 85% of the total number of PLHIV enrolled in care and treatment in the target districts. The selection was based on an initial mapping of facilities where the USAID-funded OPHID-FACE project is currently providing technical assistance to facility-based HIV care and treatment services. 3 ; Buhera; ; Bulilima; Chipinge; Chiredzi; Chivi; Gokwe South; Gutu; Gwanda; Gweru; ; Kwekwe; Makoni; Masvingo; Matobo; Mberengwa; Mutare; Mutasa and Mwenezi.

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representatives participated in the review meeting. Other key resource persons invited included FHI 360 staff from the East and Southern Africa (ESARO) office as well as Dr Kwasi Torpey, Director Technical Support Division.

In order to identify service delivery gaps in the HIV cascade, FHI 360 conducted a baseline assessment and mapping exercise in 8 districts and the findings will be critical in strengthening strategies for the delivery of comprehensive HIV community services the five-year period of ZHCT implementation. The results of the baseline assessment show that the yield rate for HTS in 2015 in the two provinces of Manicaland and Midlands was 8% across the targeted 126 health facilities. Of the clients tested for HIV and received their results, only 31% were males, which highlights limited reach to males with the current HIV testing services. Out of the 16,609 clients enrolled into pre-ART during 2015, 70% were initiated on ART according to the national guidelines. Viral load testing was virtually non-existent in Midlands. The baseline assessment results also show that 1,214 clients were collecting ARVs through community ART refill groups (CARGs). Ninety-three percent of these clients are located in Buhera where MSF has a strong presence. This highlights a gap that needs to be addressed by ZHCT to ensure that every district has functional CARGs. The qualitative data analysis noted the following gaps in HIV care and treatment services provision: lack of male involvement for HIV testing; increased number of individuals who default on ART once they feel better; and counter-productive messaging from some religious groups, as well as stigma and discrimination. The final baseline assessment report will be available at the end of October 2016.

Figure 1: ZHCT Implementation Districts

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3. DETAILED ANNUAL RESULTS AND ACHIEVEMENTS

This section presents details of ZHCT Project results for the period September 24, 2016 to September 30, 2016. Through household index testing 2,101 PLHIV were newly identified out of 20,194 people tested during the period under review. Out of the 2,101 people testing positive, 1,579 (75%) were enrolled into care (see Figure 1 below: ZHCT HIV Testing Cascade). The miss in achievement of HTC and linkage to care targets is attributed to the delay in commencement of direct services delivery at community level, as this started in March 2016. This meant that FHI 360 effectively had seven months to achieve COP 15 targets for Year 1. Concerted efforts will continue in programme year two (PY2) to track and actively link to care all the newly identified PLHIV including clearing the backlog from PY1.

Figure 2: ZHCT HIV Testing Cascade

3.1 HIV Testing Services 20,194 clients were tested; counselled and received their HIV results during the period under review. 10,137 (50.2 %) of clients tested were females while 10,057 (48.8%) were males. It should be noted that ZHCT had presence in eight out of the targeted 20 districts in Y1 although targets were set for all 20 districts. The eight districts had to absorb targets from the 12 districts as shown in Figure 3 below. Overall, the project achieved 87% (20,194/23,091) of the HTS target in the first year.

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3500 16%

3000 14% 14% 13% 13% 12% 2500 11% 11% 10% 2000 9% 8% 7% 1500 6% 1000 4% 4%

500 2%

0 0% Buhera Chipinge Gokwe South Gweru Kwekwe Makoni Mutare Mutasa

Testing Target Testing Actual Positive Target Positive Actual Yield Rate

Figure 3: HIV Positive Target versus Achievement

Out of the 20,194 clients tested for HIV, 97% (19,596/20,194) were tested through household index case testing while 3% were tested through outreach-based activities. The overall yield rate for ZHCT was 10% of which 11% was through index case testing while outreach activities had 6%. HIV testing for the project started in March 2016 and only 6.2% of the clients were tested in Q2 while most of the clients (50.3%) were tested in Q3. With targeted approach that include testing of sexual partners and networks; working flexible hours and during weekends, the project tested a total of 8,651 clients and with the highest yield rate of 16% among all quarters as shown in Table 3 below (Annual Indicator Performance Table, Oct. 2015 - Sept. 2016). In FY17, the project will prioritize this approach so that more positives are identified. The project has set a target of testing at least 60% of the sexual partners and will ethically institute a symptoms screening tool so that those most likely to be positives are identified through index case testing. As shown in Figure 4 below, nearly half of the clients tested (48%) were aged 25 – 49 years and this has been the pattern across all quarters of Y1. Of note is that this is consistent with the national level HTS data. Among this age group, more men (52%) were tested for HIV and received their results, which is slightly higher than the national average of 31%. These results suggest that the household index testing approach improves the reach of men with HIV testing services. ZHCT will therefore build on these positive lessons from Y1 into Y2 by increasing our emphasis on household index case testing as the main approach to identifying more PLHIV in the targeted communities. Just over three quarters (76%) of all clients tested, were aged 15 – 49 years, highlighting the deliberate effort by the project to reach out to the sexually active age group. However, the project continued to encounter challenges in reaching out to specific age groups such as adolescents (15 – 19 years) and young people (20 – 24 years) as their total contribution to the sexually active group is very low at 15% and 22% respectively. This was due to inadequate mobilization and targeting of these specific age groups, but this is anticipated to improve in the next programme year when FHI 360 collaborate with Africaid to mobilise adolescents and young people. Africaid has documented technical expertise and experience in reaching out to adolescents and young women through their Zvandiri model.

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12000 10000 8000 6000 4000 2000 0 <1 yr 1-4yrs 5-9yrs 10-14yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+yrs

Male Female

Figure 4: Individuals receiving HTS by Age Category

3.2 Quality assurance for household index testing All Community Health Officers (CHOs) who conduct HIV testing in the communities received training on rapid HIV testing that was facilitated by the MOHCC. HIV testing within ZCHT is conducted using the national HIV testing guidelines and algorithms. The first batch of 40 nurses were trained in March 2016 as part of building the capacity of health care workers’ skills to conduct rapid HIV testing. 22 of the trained nurses were from ZHCT while the remaining 18 nurses were MOHCC staff members from the respective health facilities that ZHCT is supporting. During the period under review, the project also developed standard operating procedures (SOPs) for community-based HTS to guide HIV testing in communities including the guidance for quality assurance processes (see Annex 111: List of ZHCT SOPs and Data Collection Tools). Internal quality controls for HIV testing are conducted daily and recorded in the ZHCT HIV Testing Register to test the integrity of the HIV test kits before any HTS services are provided to clients. District Coordinators and national technical staff use an HTS quality assurance (QA) checklist Figure 5: CHOs undergoing rapid HIV testing training during site support and supervision visits. The checklist checks whether all pre-analytical, analytical and post analytical quality assurance processes are observed for community-based HTS. Regarding community level proficiency testing, Y1 focused on advocacy and planning for community level proficiency testing. Several meetings were held with MOHCC and its partners both at national and provincial level to plan for expansion of HTS external quality assurance (EQA) from health facility setting s to community settings. In Y2, each CHO will participate in at least one EQA exercise for HTS.

3.3 HIV testing yield Figure 3 below shows that Gokwe South district had the highest overall yield rate of14% (398/2,913); while Buhera had the lowest at 4% (117/2540). The yield rate for all the districts almost doubled between Q3 and Q4, which is attributed to the targeted approach that was used in the last quarter. Buhera’s yield rate was consistently low over the quarters and this could be due to the greater number of HIV programs which have been operational in this district in the previous years, particularly through MSF. There was, however, some improvement in Buhera as with

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the rest of the districts particularly in the last two months of Q4, where it recorded approximately 11% (7% in August and 23% in September). Gokwe South’s yield rate is attributed to a number of factors such as adequate staffing over the quarters, few HIV partners operating in the district (PSI was highlighted as the main partner in the district supporting community testing4) and provision of services outside normal working hours which most public facilities do not do1. The active involvement of male Outreach Workers who also constitute a considerable proportion, helped in engaging more men in Buhera, Kwekwe and Gokwe South.

25% 20% 15% 10% 5% 0% Buhera Chipinge Gokwe South Gweru Kwekwe Makoni Mutare Mutasa Q2 3% 10% 17% 7% 10% 8% 6% 4% Q3 4% 8% 7% 7% 8% 6% 4% 4% Q4 6% 18% 21% 17% 20% 17% 11% 15% Overall 4% 13% 14% 11% 13% 11% 7% 9%

Figure 6: Yield Rate by District

The map below (Figure 7) shows the distribution of HIV positives identified and the yield rate by district.

Figure 7: HTC_Positives and Yield Rate by District

4 ZHCT Baseline Assessment and Mapping Draft Report. 2016

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3.4 Enrolment into care Among the clients who tested HIV positive, 75% were enrolled into care as shown in Figure 1 above (ZHCT HIV Testing Cascade). The enrolment into care increased from 43% in Q2 to 74% in Q4. This was due to the active referral and follow-up of newly diagnosed PLHIV by the outreach workers. Districts were having dedicated CHOs on a weekly basis who would work closely with OWs so that backlogs are cleared while the other CHOs were identifying new positives. The cases enrolled into care where confirmed by being registered in the Pre-ART or having an ART number. There are some clients have been enrolled into care in sites outside our catchment areas and this could have resulted in underreporting of this figure. The capacitation of outreach workers with mobile phone and bicycles have also facilitated in improving this referral system and getting clients enrolled into care. Overall, Makoni had the highest linkage rate while Kwekwe had the lowest as shown in the chart below. The low linkage rate in Kwekwe is due to the high mobility and work commitments of the artisanal miners and farmers. Although the project performed very well on this there are still some challenges in linking clients to care. These include patient mobility, non-disclosure, preference for facilities Figure 8: Outreach Workers receive bicycles, phones and bags outside catchment areas, user fees in some health facilities, as well as unavailability of clients due to work commitments, particularly in farming and artisanal mining (makorokoza) communities. The project’s Community Program Facilitators will continue to sensitize communities on the importance of utilizing HIV services, which will in a way, reduce stigma and enhance disclosure.

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450 100%

400 90% 86% 80% 80% 350 77% 79% 74% 70% 300 63% 58% 60% 250 56% 50% 200 40% 150 30%

100 20%

50 10%

0 0% Buhera Chipinge Gokwe Gweru Kwekwe Makoni Mutare Mutasa

Positive Linkage Linkage Rate

Figure 9: Linkage Rate by District

In Q4, ZHCT sampled five sites in each implementing district to assess the number of clients who were enrolled into care (pre-ART) and eventually initiated on treatment. An average of 94% of these clients in Manicaland were initiated on ART because of the Treat All approach which was implemented in that province as a learning initiative. However, in Midlands this varied from one district to the other with Kwekwe having almost 28% initiated on ART while Gokwe South had almost 90% initiated on ART as they had adopted the test and treat approach. Collaboration with PSI so that newly diagnosed PLHIV can be initiated in the communities will help in mitigating some of the highlighted challenges. Overall, the linkage/enrolment rate by age category is good across all age categories as shown below. In Q2 and Q3 we had most of the clients aged less than 15 years being linked with the linkage rates as high as 89%. This was believed to be due to the family support. Following the introduction and capacitation of Outreach Workers, they were encouraged to engage the sexually active (15 – 49 years) age group. This brought positive results as the linkage rate improved across all age categories. This will help in curbing HIV transmission in the communities as more of the sexually active PLHIV will be enrolled on ART.

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1600 79%

1400 78%

1200 77% 1000 76% 800 75% 600 74% 400

200 73%

0 72% <15 yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+yrs HIV Positives Identified 94 73 285 1430 219 Linked to care 72 57 212 1067 171 Linkage rate 77% 78% 74% 75% 78%

HIV Positives Identified Linked to care Linkage rate

Figure 10: Linkage Rate by Age Category

Yield rate by source of Index cases

18000 25% 16000 22% 14000 20% 12000 15% 10000 15% 8000 10% 11% 11% 11% 10% 6000 8% 4000 5% 2000 0 0% OI/ART (Pre- Inpatient ANC/PMTCT OI/ART OPD (TB) OPD (STI) OPD (VCT) ART) Tests Done 450 1015 66 15471 464 926 293 HIV Positives 36 104 7 1659 50 137 64 Yield 8% 10% 11% 11% 11% 15% 22%

Figure 11: Yield Rate by Source of Index cases

The yield rate in the DREAMS5 districts was generally low (0-5%) among males aged 15 – 19 years. The yield rate among females aged 15 – 19 years was highest (10%) in Gweru as shown Figure 12 below. Among those aged 20 –

5 DREAMS is a partnership to reduce HIV infections among adolescent girls and young women in 6 districts (Bulawayo, Gweru, Mazowe, Makoni, Mutare and Chipinge). The goal of DREAMS is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women.

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24 years, the yield rate was much higher among females compared to male counterparts. This highlights how vulnerable young female are in these districts.

Figure 12: Yield Rate by Age Category in DREAMS Districts

Overall, the yield rate was highest in Q4 particularly in August and September when the project improved its targeting approach as well as use of data. Of note is that, from Q2 to Q3 the number of clients testing positive increased six-fold while overall testing went up by almost ten-fold.

5000 45.0% 4500 40.0% 4000 35.0% 3500 30.0% 3000 25.0% 2500 20.0%

2000

Yield Rate Yield Individuals 1500 15.0% 1000 10.0% 500 5.0% 0 0.0% Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Tested 1285 1964 4032 4262 4298 2972 1381 Positive 103 136 223 271 301 478 589 Yield Rate 8.0% 6.9% 5.5% 6.4% 7.0% 16.1% 42.7%

Figure 13: ZHCT Annual HTS

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Figure 13 above summarises the yield that was achieved because of a change of approach in the last quarter (Q4) to targeting and testing sexual partners. There was an improvement in yield in all the districts with Kwekwe recording the highest yield among sexual partners of 63% (86/136) while Buhera had the lowest 27% (30/122) as shown in Figure 14. The overall yield for sexual partners tested was 38% while that of children was the lowest (6%). In FY17 the project will continue to intensify the testing of sexual partners in order to identify more HIV positives.

600 70%

500 60%

50% 400 40% 300 30% 200 20%

100 10%

0 0% Gokwe Buhera Makoni Mutasa Chipinge Gweru Mutare Kwekwe South Tested 112 522 327 442 150 230 108 136 HIV Positive 30 146 105 153 72 116 57 86 Yield 27% 28% 32% 35% 48% 50% 53% 63%

Figure 14: Yield for Sexual Partners

3.5 Symptom Screening ZHCT aims to screen for TB among all newly diagnosed PLHIV. During the period under review, the project achieved a 99.6% (2096/2101) performance on this indicator. Early identification of active TB disease among PLHIV is very important as the co-infection of TB and HIV results in death in most cases. Out of the 2096 cases screened for TB, 1,116 clients were referred to the health facilities for further tests and management and only 69% completed this referral. The provision of symptom screening of non-communicable diseases and other conditions as part of a comprehensive package of services helps reduce the stigma and discrimination associated with HIV. Referral completion for services such as diabetes mellitus, hypertension, family planning and VMMC remained low. Some of the challenges are linked to user-fees, distances to service points, drug shortages etc. ZHCT will continue to work with facilities and communities to improve referral completion among symptomatic clients as the spill-over effect will improve referrals for those newly diagnosed PLHIV. The table below summarizes the project’s performance on TB screening. Table 1: TB Screening TB Screening Male Female Total Tested 10,037 10,157 20,194 Positive 927 1,174 2,101 Screened for TB 925 1,171 2,096

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3.6 Defaulter Tracking Out of the 4,661 clients who were registered as ART defaulters during the period under review, 4,473 (96%) were tracked and of these 3,470 (78%) were identified. 1,710 registered ART defaulters were successfully returned to care as shown in Figure 15 below. In this period, eighty percent (80%) were successfully returned to care in Q4. This is due to the active tracking by the Outreach Workers. Of note, is that more than a quarter (27% [944/3,470]) of the clients identified were confirmed to be still in care. These findings suggest inadequate documentation at facility level, which resulted in over-targeting in Y1 of defaulters to be tracked under the project. In Y2, ZHCT will support health facilities in updating registers such as Appointment Diary, pre-ART and ART registers.

Figure 15: Defaulter Tracking Cascade

3.7 PLHIV receiving ARVs through CARGs 383 functional CARGs have been formed and strengthened by the ZHCT project in FY16, with Manicaland having the most groups (72%). The CARGs supported have a total membership of 3,118 PLHIV currently receiving ARVs within the community and female members constituting 67%. The majority (65%) of the members are in the 25 - 49-year age group and during the period under review, only one member died. The majority of the CARGs (96%) receive three months ARV supply with the remainder receiving two months’ supply. Out of the all the functional CARGs, 519 members in three districts had a valid viral load with Buhera having the majority (99%) and the rest from Mutare, Chipinge and Mutasa. All of the viral load results are less than 1,000 copies/ml indicating a suppressed viral load among the members of these CARGs.

3.8 PLHIV receiving care and support services outside of the health facility 10,937 clients (Manicaland: 4,090, Midlands: 6,487) were reached with a wide range of services mainly aimed at improving the retention of PLHIV within care, treatment adherence and linkage to other health services. The highest number of PLHIV (26%) (2,876/10,937) were reached with services in Gweru while the least 6% (662/10,937) were recorded in Makoni. Out of the 10,937 PLHIV reached with services, 69% of the clients are in the 25 – 49-year age category with females constituting the greater proportion (62%) PLHIV served. Of note is that a very small proportion of <1 year olds (0.2%) received services through linkage to the health facilities for DBS after having been identified as being exposed to HIV within the community. The aggregation of individuals served however, presented the teams with challenges considering the possible overlap of services provided to PLHIV. Therefore, the numbers of PLHIV who were served was adjusted so that individuals were counted only once in the aggregated total. The individuals that received services through CARGs and were referred to other health services were de-duplicated at the district reporting level.

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4. PERFORMANCE INDICATOR SUMMARY

Table 2: Annual Indicator Performance Table, Sep. 2015 - Sept. 2016

Annual Annual Targets Indicator Deliverable Q1 Q2 Q3 Q4 Achievement (Oct 15 – Sep 16) Number of individuals who receive HIV Testing and Number of individuals tested for HIV Counselling (HTC) services for HIV and received their test 0 1285 10258 8651 20194 23091 and received results results Number of individuals diagnosed with % of clients testing HIV+ during reporting period 0% 8% 6% 16% 10% 10% HIV

% of new PLHIV who were screened for TB symptoms at Number of clients screened for TB 0% 95% 100% 100% 100% 90% the community level during reporting period symptoms

% of new PLHIV who are successfully linked to care during Number of clients successfully linked 0% 43% 45% 91% 75% 70% reporting period to care % of clients with completed referral to the health facility Number of clients referred 0% 29% 47% 91% 74% 70% for health services Number of HIV+ adults and children newly enrolled in Number of clients enrolled in clinical 0 44 286 1249 1579 2075 clinical care (pre-ART) during the reporting period care Number of individuals trained in one or all of the following: HIV Testing; HIV Care; HIV Treatment; GBV during the Number of individuals trained 0 0 1393 103 1496 248 reporting period Proportion of ART defaulter clients tracked and successfully ART defaulter clients tracked and 0% 3% 68% 73% 68% 80% returned to care during the reporting period linked back to care Number of CARGs formed or identified and capacitated on community HIV services provision within a reporting CARGs formed 0 15 219 121 383 100 period Number of PLHIV receiving ARVs at the community level through refill groups during refill groups during the report PLHIV receiving ARVs 0 159 1461 2198 3118 960 period Proportion of clients successfully linked to care for viral Number of clients with viral load tests load testing from the community during the reporting N/A N/A N/A N/A N/A done after referral period

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5. LABORATORY SERVICES STRENGTHENING

Concerning laboratory services strengthening, ZHCT achieved the following key results during the period under review: -

 Initiated the procurement of 6,600 viral load reagents to support MOHCC Viral Load Scale Up. ZHCT worked closely with the MOHCC National Logistics Unit and participated in several national quantification meetings to plan for the procurements and logistics of VL reagents. Several meetings were held with the Association of Public Health Laboratories (APHL) supporting viral load scale up to avoid duplication and to maximize efficient use of PEPFAR resources.

 Human resources for health: The project seconded three Laboratory Scientists and one Data Entry Clerk at Mutare and Gweru Provincial Hospitals in Year 1. The seconded Laboratory Scientists and Data Entry Clerk were oriented on the different protocols to ensure quality VL sample reception, processing and result transmission to health facilities. They also received a one-week attachment at NMRL PCR laboratory as part of their orientation program to ensure that they understand VL PCR processes and protocols. At the provincial laboratories, they also received an intensified on the bench training on the Roche VL platform and VL testing processes. The ZHCT project staff were oriented on VL testing, including demand generation at community level. In Y2, ZHCT field staff will be oriented on VL sample collection, transportation, and enhanced adherence counselling (EAC) for clients with high viral loads (VL more than 1,000 copies/ml).

 Provided technical assistance to MOHCC Viral Load Scale Up Plan: FHI 360 provided technical assistance to the viral load technical working group (TWG) through participation in various meetings and in the development of viral load testing tools and scale up plans. FHI 360 chairs the sub-committee developing viral load community sensitization package.

 Supported the renovations of Gweru and Mutare provincial laboratories to facilitate setting up a viral load PCR laboratory. The renovations included partitioning, painting, tiling, fitting workbenches, glass doors, tinting of windows, installation of air-conditioning systems to mention a few. Both laboratories started running VL testing in Q4 of FY16. Minor renovations at Mutare Provincial Laboratory and procurement for VL ancillary equipment are planned for FY17.

 VL Sample transportation: ZHCT field-based staff in Manicaland and Midlands provided technical assistance in the development of functional sample transport mechanisms at provincial level TWGs. ZHCT complements the MoHCC existing sample transportation system using its network of motorized ZHCT project staff. Duiring the period under review, 385 samples were transported to the Mutare provincial lab. Midlands did not support any VL transport as the provincial lab was still doing start up activities. The transport VL samples from point of sample collection to district hospitals where the samples are spun within six hours of collection before onward transmission to the provincial laboratories were the VL testing is conducted. For sites that are close to the provincial hospitals, the samples are transported to the provincial laboratories within 6 hours of collection.

 Demand generation for viral load testing: Demand generation to ensure increased uptake of viral load services was conducted in Manicaland and Midlands through the ZHCT field-based staff. VL demand generation materials were developed for the ZHCT project and are in use for the VL demand generation efforts that are being conducted within the ZHCT project. Community sensitizations on VL were to disseminate messages and information to PLHIV and their communities about the importance of viral load testing, how it relates to adherence and ensuring a good understanding of the meaning of detectable versus undetectable viral load levels. Viral load testing literacy materials for adults were developed to empower PLHIV to both request that a VL test be performed at the appropriate times and to understand the result and consequences. Demand generation will be intensified in FY17 now that there is improved access to VL in the two provinces. Community-based

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healthcare workers and outreach workers in the ZHCT project will be oriented on VL demand generation to ensure understanding of the benefits and interpretation of viral load testing results.

 Quality assurance for VL: The ZHCT project provided technical assistance in the VL technical working group to ensure that a VL Quality Assurance Program (QAP) that is designed to monitor, evaluate, and improve the quality of testing and to evaluate the competency of the laboratories to produce results that are of high quality. The ZHCT is providing technical oversight in ensuring that the Mutare and Gweru Provincial Laboratories have VL QA programs and protocols in place and that they are enrolled in the national VL Proficiency Testing Programs.

6. CHALLENGES ENCOUNTERED

During the course of implementation, ZHCT faced several challenges, both programmatic and administrative, that had a negative bearing in smooth progress towards the achievement of set COP15 annual targets. One main challenge encountered was delays in finalizing the FY16 work plan due to revision of the ZHCT project technical focus and approach. This resulted in delays in project implementation including in identification of HIV positives, enrolment into care, defaulter tracking and other HIV treatment services at community level. To mitigate this, FHI 360 developed an Accelerated Implementation Plan in Q2, which helped outline priority activities to facilitate commencement of provision of HIV care and treatment services in the targeted communities.

Table 4 below outlines the other key challenges encountered in FY16 and mitigation measures/ approaches that were put in place to address these challenges.

Table 3: Challenges and Mitigation Measures Challenge Mitigation measure/ approach Programmatic/Technical Challenges 1. Poor targeting of sexual partners of index cases  Improved targeting to reach out to sexual partners of and low yield among individuals tested the index cases.  Implemented more innovative approaches for the men who are usually at work during the time household visits are conducted e.g. flexible working hours, testing in workplaces.  Revision of the HTS register to allow for better analysis of the yield across the different target groups 2. Engagement of adolescents and young men and  Collaborate with Africaid in high volume districts in women remains poor Year 2 to improve mobilization, linkage to care, defaulter tracking, etc. of this age group 3. Intermittent stock-outs of rapid HIV test kits at  To avert interruptions in service delivery within the facility-level because of the shortage at national ZHCT, district teams mobilized and redistributed level owing to delays in the delivery of the these test kits from the other facilities. expected shipments.

4. Poor documentation in health facility registers  Engaged Outreach Workers, who among other duties affecting tracing and tracking of defaulters. Up support with updating the facility appointment diary to a 1/3 of clients registered as defaulters are not true defaulters

5. Limited availability of viral load testing services  ZHCT project in collaboration with MOHCC, USAID in both provinces. and APHL supported the scale up of viral load services through renovations of the two provincial labs and secondment of lab scientists and data entry clerks. APHL placed VL Roche machines and reagents at the two provincial labs

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6. Poor filling of referral slips at facility level  The ZHCT district team including outreach workers (especially the district hospitals) where the adopted a rigorous follow up protocol/mechanism in relevant facility staff cite heavy workloads as order to ensure that referrals are complete within one the cause for not filling the tear off slips. week of referral. Resultantly, slips end up not being filled and referrals are lost along the way. Administrative/ Operational Challenges 7. Lack of adequate financial monitoring which  Corrective measures as detailed in the ZHCT resulted in overly rapid spending against Mitigation Plan put in place and are being allocated funds, which led to depletion of the implemented. FY16 obligation before the end of the fiscal year and a significant immediate cash flow challenge, representing a major financial risk to the long-term future of the project.

8. Delays in finalizing provincial and district level  Following protracted discussions and negotiations, FHI MOUs which delayed district level entry and 360 eventually successfully managed to sign MOUs implementation of activities with the 13 local authorities for both rural and urban council in FY16 implementation sites 9. Transport challenges: Despite having procured  Training and certification of the majority of CHOs in 11 vehicles and 30 motorbikes for the project, motorbike riding was conducted. training of CHOs in riding a motorbike was  As we scale up in COP16, to plan for and prioritize delayed due to trainers’ prior commitments. training of CHOs on motorbike riding This resulted in reliance on the district vehicle. However, considering that in our approach, testing is conducted at household level, mobility within the teams was limited as the team members could not visit different areas simultaneously.

10. User fees for clients: In some health facilities,  Advocated with the DMOs in the respective districts particularly those that are council-run, which to work with the Local Authorities to waive user fees charge $2 to $5 to clients per every visit. This for OI/ART clients and explore other ways of contributes to the increase in defaulter rates generating income and acts as a barrier to linkage as some clients cannot afford the fees.

11. Inappropriate waste disposal: There are no  Planned to support construction/ renovation of incinerators at 22 primary health facilities incinerators at these facilities in COP16 to allow for especially in Midlands. CHOs have to resort to appropriate waste disposal in line with ZHCT transporting waste to district facilities for Environmental Mining and Mitigation Plan. disposal posing a health risk.

7. MONITORING AND EVALUATION

The ZHCT M&E unit coordinated the compilation and analysis of project data from Midlands and Manicaland for the period under review. Weekly progress reports were provided through a performance dashboard and these helped in assessing achievements against the set targets. In addition, the team provided an interpretation of the weekly performance to the district teams and also outlined key action points for teams to address gaps and also consolidate on the successes. The following were the main activities implemented: -

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 Database Systems: During the initial stages of the project, a review of various health information database systems was conducted in order to select one that would best fit the requirements of the project. The DHIS2 was selected as it was not only appropriate for the project but is also widely used within the Ministry of Health and Child Care to capture, analyze and report data. An experienced consultant in setting up and customization of the DHIS2 was engaged. The first quarter of FY17 will be for deployment and testing of the system with live data across two districts, starting with the aggregate data module then phasing in to the patient level data capturing using the DHIS2 Tracker. The project has continued to make use of the weekly performance dashboard to provide near-real time data to inform programming

 Data Collection Tools: Data collection tools (DCTs) and Standard Operating Procedures (SOPs) were developed and adapted for the project with involvement of the AIDS and TB Strategic Information Unit to ensure alignment of tools with the MoHCC. During implementation, DCTs were reviewed and four tools i.e. HTS Register, Symptoms Screening Tool, Patient Tracking Register and Index Case Register were adjusted to make sure they collected the critical data. With regards to third 90, viral load testing data will be routinely analyzed as part of the data quality assessments and for purposes of providing remedial action as required. The project will use the final national VL request form and VL sample delivery checklist

 Technical Support and Supervision: Quarterly visits to the provinces were conducted during the period under review to provide technical support and supervision. These were participatory and were aimed at promoting mentorship, joint problem-solving and communication amongst the district teams. There have been some improvements since the inception of the project as district teams were continuously improving with each subsequent quarter on use of different Data Collection Tools (DCTs) and their understanding of the indicators

 Data Quality Audits: Data verification and improvement was conducted using the FHI360 Data Verification and Improvement Tool (DVIT). The data verification processes involved recalculating results from source documents using a simple calculation to determine the accuracy of reported data. The level of accuracy was measured by percentage variance (+5%/-5%), which was defined as the variance between the recalculated value compared to what was reported. Data improvement was then conducted to as a guided process to identify root causes affecting data quality and to develop immediate and long-term plans for addressing threats to data quality. During the period under review, the team administered the DVIT in selected districts. For each data issue identified, corrective actions were proposed and specific follow up actions outlined. The teams received follow up support to ensure the data issues were addressed adequately

 Quarterly Data Review: Since the inception, the two provinces have been conducting quarterly data review meetings to review and interrogate data so as improve programming and inform progress. Part of the review meetings also focused on service availability and the project’s achievements within the targeted districts and considering the opportunities and challenges faced. Overall, the meetings provided a platform for district teams and the technical team to discuss the project activities, identify areas that require strengthening and sharing of experiences across districts

 Baseline Assessment and Mapping Exercise: During the reporting period, the team conducted a baseline assessment after permission was obtained from the Ministry of Health and Child Care (MoHCC), Medical Research Council of Zimbabwe (MRCZ) and FHI 360’s Institutional Review Board (IRB). Data was extracted from 126 health facilities (targeted tier 1 and tier 2) in the two provinces, focusing on 18 selected indicators for data collected in twelve months of 2015. Key informant interviews were held with representatives from the MoHCC, NAC, NGOs and community leadership. The data collected was analyzed, a report was compiled, and this will be shared with USAID and MoHCC.

8. ZHCT PROJECT COLLABORATION WITH OTHER PARTNERS

ZHCT works closely with MOHCC and other implementing partners, funded by both USAID and other donors to ensure the harmonization of project activities with national response framework as well minimize duplication of effort by others. Some of the key partners that FHI 360 collaborated with during the period under review include

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OPHID Trust, APHL, EQUIP, PSI. The project provided technical assistance to the MOHCC through participation in key partnership forum meetings and technical working group meetings at national level; PMTCT, HIV Care and Treatment, HIV Prevention, Laboratory Services, Viral Load, Forecasting and Quantification. The project also provided technical assistance during the adaptation of the 2015 WHO guidelines for HIV prevention, care and treatment. In addition, the ZHCT provided technical assistance to the National Microbiology Reference Laboratory (NMRL) as well as to the provincial laboratories on the Laboratory Information Management System (LIMS). The LIMS will be used to store and manage information associated with PLHIV data and specimen information for VL. ZHCT contributed to the drafting of the operational plan for the national VL LIMS. Once the LIMs development and piloting is completed at NMRL, ZHCT will facilitate its roll out at Mutare and Gweru provincial hospitals. Currently, ZHCT-seconded data entry clerks support the entry, analysis and summation of VL testing data at the provincial laboratory.

9. FHI 360 REGIONAL AND TECHNICAL SUPPORT

In order to strengthen the capacity of the local team, FHI 360 regional team provided oversight and technical support during the course of the year. Key ZHCT project staff were oriented on Contract Management Systems (CMS) of handling USAID awards by the FHI 360 East and Southern Africa Regional Office (ESARO). The ESARO team also oriented key ZHCT project staff on procurement management, sub-grantee management, travel management and USAID administrative and financial compliance requirements. All key FHI 360 and Plan International project staff attended a one-week training on Sub-Award Management in Harare. These orientations ensured increased compliance with USAID Rules and Regulations as the FHI 360 Zimbabwe team executed the Cooperative Agreement.

ZHCT technical team participated in a one-week training on DHIS2 tracker in Rwanda and Strategic Information/M&E FHI 360 Global workshop on implementation approaches such as data quality assurance, data analysis and use. In addition, ZHCT finance staff also attended an FHI 360 one-week training in Senegal that covered procurement management, sub-grantee management, travel management and USAID administrative and financial compliance requirements.

10. ADMINISTRATIVE AND OPERATIONAL ISSUES

During the period under review, national, provincial and eight district offices were secured for the project. All the 10 ZHCT project offices from national, provincial and districts levels have been branded in line with the Branding and Marking Plan. The branding has increased visibility of the project at all levels. All the offices have been connected with internet, increasing the efficiency and effectiveness of project operations in the field towards achievement of targets.

Eleven project vehicles were procured to facilitate project implementation. Six vehicles were allocated to Manicaland province while four were allocated to Midlands province and one was retained at national office in Harare for coordination purposes. During the baseline assessment, 10 vehicles were leased for Manicaland and Midlands provinces with an allocation of six and four respectively. This facilitated the smooth collection of data at health facility level, engagement of key informant interviews as well as focus group discussions.

Twenty-two motorbikes were procured and distributed to the eight districts for use by the Community Health Officers. Twenty of the CHOs were trained by the Riders for Health on how to use the motorbikes. It is anticipated that this improved mobility by the CHOs will further improve household testing, particularly accessing hard-to reach communities. 200 bicycles, mobile phones and bags for the Outreach Workers were purchased and handed over in May 2016. This equipment helped increase the efficiency of project operations in the field towards achievement of targets as from Q3 going forward.

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11. LESSONS LEARNT

FHI 360 identified a number of key lessons learnt during Y1 of ZHCT implementation, and these will inform programming in subsequent years on the five-year project duration. The following are key lessons learnt: -

 Engagement of key stakeholders facilitates project entry and successful implementation of the project. The letter of support from the Permanent Secretary including the engagement with PMDs facilitated smooth entry into the two provinces and the 8 districts. Engagement of the Local government (PA, DA and Traditional leaders) facilitated better acceptance and project implementation at community level. The signing of MOU at district level was a pre-requisite for project entry within the districts

 In FY16, the ZHCT project demonstrated that household index case testing is feasible when instituted after good community sensitization. However, this approach is resource intensive due to the processes that need to be instituted such as community sensitization, mobilization, identification of index cases at health facility level, prior engagement of index cases by Outreach Workers (visits or phone calls) and follow up for household HIV testing by the CHOs and follow ups conducted to ensure referral completion for the HIV positives. Resources required included transport, human resource, staff time, communication etc.

 Bringing HIV testing services to the household has the potential to reach to more men as has been shown by FY16 results. In Year 1, the project has reached more men (44%) than women through index case testing as compared as compared to 25 – 35% from the 2015 MoHCC HTC program data. The ZHCT innovative approach will improve the overall HTS coverage among men in the targeted districts, and positively impact national coverage as the project expands to more provinces and districts in the subsequent years of implementation

 The experience Midlands and Manicaland indicates that proactive engagement with key technical partners in the provinces is crucial for rapid take-off of program, while ensuring that the activities are technically sound. Proactive engagement and coordination with other key HIV care and treatment partners in the provinces is crucial to minimize duplication of efforts and maximize on efficiency. Active and formal collaboration with OPHID through an MOU has helped to clarify roles and operating space for each partner. A similar approach will be pursued with other partners implementing HIV care and treatment activities e.g. PSI.

 Securing adequate office space in rural settings is a challenge and therefore, prioritizing this activity will be crucial as the project scale-up to the other provinces

 Targeting of sexual partners of index cases and exploring the sexual networks is critical in achieving a higher yield among individuals tested for HIV. In Q4, following revision in targeting and HTS register, 2027 of individuals tested were sexual partners of the index cases resulting in an average yield of 38% (765/2027)

 Innovative approaches (e.g. flexible working hours) are essential to target men who are normally at work during the time CHOs conduct household visits

 Engagement of adolescents and young men and women in the project has been slow. Hence innovative and dynamic approaches that are tailor-made to their needs are essential

 Involvement of community cadres like the community-based expert patients (Outreach Workers) is critical in improving linkage to care and treatment (particularly in defaulter tracking). However, documentation challenges in health facilities have resulted in misclassification of some patients whom upon follow up, up to a third of clients recorded at the facility as defaulters have been found to be still in care and up-to-date with their scheduled appointments

 Stigma and disclosure remain a challenge to successful linkage and enrolment in care of newly diagnosed PLHIV.  There is a difference in the acceptance of CARGs as an appropriate service delivery model by PLHIV and facility nurses between urban communities and rural communities. As a model, CARGs are more acceptable in rural areas as compared to urban communities

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 Near real time data at all levels is crucial to track performance and address gaps in low performing districts such as Buhera and Mutasa.

12. LOOKING AHEAD: ZHCT PRIORITIES FOR YEAR 2

The focus of ZHCT in FY16 was on establishment while FY17 (October 1, 2016 to September 30, 2017) will focus on consolidation in existing districts and expansion into additional new districts. In FY16, FHI 360 will intensify implementation of differentiated care models through district-specific strategies to achieve optimal HIV testing yield, improved linkage to care, retention and defaulter tracking. The following are key plans for ZHCT in FY17: -

 Add 5 new districts (Chivi, Gutu, Masvingo, Mwenezi and Zaka) in and cover an additional 81 health facilities. The target number of HIV positives to be identified and linked to care in the 13 districts through household index testing is 15, 262 (i.e. 3, 132 paediatrics and 12, 130 adults).

 Support implementation of Treat All at community level  Support MOHCC to strengthen laboratory services through various activities including quality assurance for HTS, laboratory human resources capacity strengthening as well as demand generation for viral load testing

 Recruit locum nurses to complement the current Community Health Officers as a cost-containment measure in human resources and to ensure that set targets are achieved.

 Continue collaboration with other USAID partners including OPHID Trust to strengthen community-health facility linkages for increased HTS uptake

 Support EQUIP to implement models of community ART delivery in non-multi month dispensing (MMD)/CARG study sites; on cost-outcome analysis of implementing different community models of MMD in different settings; as well as support the demand creation and literacy for viral load monitoring for PLHIV in the community. For further details on these key priorities and other activities for FY17, refer to ZHCT Year 2 Annual Work plan submitted as a separate document.

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Annex I: ZHCT Annual Progress Summary Baseline data FY 2016 % Annual Performan Indicator Data Source Annual Comment(s) 2016 Value Annual Target Cumulative ce Reached Achieved Core Indicators 1.0 Number of individuals who receive HIV Testing and HTS Counselling (HTC) services for HIV and received their test 2016 N/A 23,091 20,194 87% results Register 2.0 Number of HIV-positive adults and children receiving care and support services outside of the health facility 2016 N/A 31,788 10,937 34% Customized Indicators Intensify community based HIV Testing Services The annual positivity 3.0 Percentage of clients testing HIV positive during the HTS rate was 10% with 2016 N/A 5% 10% 10% reporting period Register Midlands 13% and Manicaland 9% yield. Integrated Symptom screening and referrals 4.0 Percentage of new PLHIV who were screened for TB HTS symptoms at the community level during the reporting 2016 N/A 90% 100% 100% period Register

5.0 Percentage of new PLHIV who are successfully linked to Referral 2016 N/A 70% 75% 75% care during reporting period Register 6.0 Percentage of clients with a completed referral to the Referral 2016 N/A 70% 74% 74% health facility for health services Register 7.0 Number of HIV-positive adults and children newly Pre-ART enrolled in clinical care (Pre-ART) during the reporting 2016 N/A 2075 1579 76% period [CARE_NEW Adapted] Registers

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Identify, target and build capacity of priority community based health workers for effective community level service delivery 8.0 Number of individuals trained in one or all of the Capacity following; HIV testing, HIV care, HIV treatment, GBV Building 2016 N/A 248 1496 648% during the reporting period Register Improve retention in care and treatment

9.0 Proportion of ART defaulter clients tracked and Patient successfully returned to care during the reporting period Tracking 2016 N/A 80% 68% 68% Register Strengthen access to viral load services through demand creation and referrals 10.0 Proportion of clients successfully linked to care for viral Procurement of Referral reagents was not done load testing from the community during the reporting 2016 N/A B+5% N/A N/A period Register in time which delayed the VL testing Support the formation and function of community level ARV Refill clubs CARG 11.0 Number of support groups formed or identified and Summary Register and capacitated on community HIV services provision within a 2016 N/A 100 383 398 reporting period Capacity Building Register Support the formation and function of community level ARV Refill clubs 12.0 Number of PLHIV receiving ARVs at the community level CARG through refill groups during the report period. Monitoring 2016 N/A 960 3,118 325% Register

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Annex II: Year 1 Implementation Update

Activities Key Benchmarks/Deliverables Status Project Start Up Activities  Conduct project planning and orientation meetings with key stakeholders at central and  At least one planning meeting held with key stakeholders Done provincial level. at each province and at national level  Recruit and position key personnel and other project staff.  100% of key project staff positioned at central level Done  Establish sub-agreements/subcontracts/MoUs with all key partners.  Sub-agreements/subcontracts in place with key partners at Done district and community levels  Finalize annual work plan, PMP and M & E plan for submission to USAID.  Annual work plan, PMP and Budget submitted and Done approved by USAID Conduct a landscape analysis in collaboration with stakeholders  Design and develop data capturing and mapping tools  Data capturing tools available Done  Conduct district service mapping in 8 targeted districts.  Districts service availability maps Done The final ZHCT Baseline Assessment Report will be shared by end of October 2016  Identify and map key hot-spots to be reached in each district with target populations  Hot spot maps generated for use by Project staff and CBHW Done  Mapping of youth friendly service providers targeting adolescents, girls and young women as well as  Report available for planning and implementation Done OVC  Conduct FGDs and IDIs in the target districts to understand quality of care and barriers to access and  Barriers to access and retention identified for programing Done retention in the context of gender and other social norms purposes  Collect baseline facility-based retention, viral suppression and related data in collaboration with OPHID  Key set of MER indicators constructed and recorded from facility Done data  Identify family planning services available at community level  List of community-based distributors of FP commodities Done Intensify community based HIV testing services  Development of Integrated Package for community based HTS  Integrated Package developed and in place Done  Orientation of CHOs and CPFs on index testing  No. of project staff oriented Done  Orientation of CBHWs on index testing  No. of CBHWs oriented Done  Community engagement and consultative meetings with MoHCC, PLHIV groups and other stakeholders  Stakeholder buy-in, ownership and commitment Done to promote household HIV testing  Develop/adapt SOPs (index case testing; data management; and tracking)  SOPs developed Done  Refresher training of community health officers in index patient testing  No. of CHO trained in index patient testing Done  Identification of index patients through PMTCT, TB, VMMC, PSI outreach, OI clinics, care groups and  Household members tested Done refill groups and follow on visit to household members of the patient  Provide HTS in hotspots  Clients tested and linked to care and treatment services Done  Introduce a risk and vulnerability screening tool for HIV negative individuals to all Outreach Workers  Screening tool used by all Outreach Workers. Done

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 Strengthen risk reduction counselling and HIV re-testing for HIV-negative clients  HIV negative clients remain negative Done  Conduct quarterly QA and supportive visits by the DNOs and the District Coordinators  Quarterly QA and support visit reports Done  Conduct routine quality assurance of testing in line with ZINQAP  Quality testing provided to clients Done  Establish functional community/facility referral systems in each district  Clear referral system established Done  Review the ZIMPHIA study on Door to Door HIV Testing to assist ZHCT decide on the applicability of  Recommendation for ZHCT Door to door testing model Not Yet the model Provide symptom screening services and referrals at community level  Adapt integrated care and support screening checklist for community cadres - to include TB, NCDs, FP,  Checklists available for use Done nutritional status and GBV  Orientation of community health officers and CBHWs in symptom screening using the integrated  CHOs, Outreach Workers and VHWs skilled in symptom screening Done checklist  Support the routine application of the integrated checklist by CHOs, Outreach Workers, VHWs and other  Increased TB case detection, Identification of malnutrition, and Done community cadres NCDs. Identification of unmet FP needs and improved linkage to care  Strengthen referrals and linkages for symptomatic patients  Complete referrals for symptomatic patients Done Identify, target and build capacity of priority community-based health workers for effective community level HIV services delivery  Identify key community based health workers that will be targeted as the mechanism for delivering  VHWs, Outreach Workers, Expert Patients identified for capacity Done community based services strengthening  Develop integrated training package for community based health workers  Integrated curriculum that addresses relevant technical areas Done developed – treatment literacy, adherence counselling, IPC, FP, nutrition, index patient testing, Viral Load and M&E  Orientation of community-based health workers in relevant technical areas – treatment literacy,  No. of community-based health workers oriented Done adherence counselling, IPC, FP, nutrition, index patient testing, Viral Load Improve retention in care and treatment  On-job refresher trainings of CBHWs on adherence counselling  No of CBHWs receiving on-job training Done  Orientation of outreach workers and VHWs on adherence using the integrated package  No. of Outreach Workers and VHWs oriented Done  Promote testing, early treatment, PHDP framework and address barriers to adherence particularly with  Political, traditional and religious leaders engaged for promoting Done political, traditional, religious leaders adherence, testing and treatment and positive living  Utilize social media platforms to promote retention in care  Social media platforms for addressing retention utilized Done  Generate defaulter and LTFU list on a weekly basis  Defaulter/LTFU lists available Done  Reconcile community and health facility based registers to identify defaulters  Defaulter lists routinely generated Done Strengthen support groups and care groups at the community level  Facilitate the formation and strengthening of support groups  No. of support groups formed and functional/ active Done  Mobilize communities to support and facilitate adolescent testing for HIV  Communities engaged and are active in supporting adolescent Done testing  Mobilize adolescents to take up testing services through the adoption of the ZVANDIRI model  Increase in number of adolescents presenting for testing Not Yet Afrcaid will be contracted to support with reach adlescents and young women in Yr 2  Establish adolescent support groups  Adolescent support groups established and functional Not Yet

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See comments above.  Facilitate the hosting of community health events, e.g. men’s health days, family health days  No. of community health events supported Ongoing  Facilitate community engagement sessions with adolescents, pregnant mothers and young women and  No of community engagement sessions conducted per target Ongoing men group  Link groups with role models for cross learning and sharing of good community based care and treatment  Skills transfer from mentor to mentees Ongoing practices  Facilitate linkages and referrals with other IPs for care and treatment support services  No of clients linked/ referred for appropriate services Ongoing Support formation of community ARV Refill Groups  Support the MOHCC to conduct stakeholder consultation for the development of the Community  Stakeholder consultation report developed and disseminated Ongoing Delivery of ART framework  Provide Technical Assistance to MoHCC for the development of the strategic framework for the delivery  A National Framework is developed and finalized Ongoing of community based HIV care and treatment services  Develop guidelines and SOPs for supporting ART refill clubs  SOPs developed/ adapted and in place Done  Facilitate the establishment of the ART refill groups for adherence and retention in care and treatment  ART refill groups established in the 2 provinces Done for PLHIV  Conduct orientation for the ART refill groups  ART refill groups oriented Done  Support ART refill clubs meetings through the Outreach Worker  All ART refill clubs are functional Done Strengthen access for viral load services  Conduct referrals for viral load testing  PLHIV referred for VL test Ongoing  Develop/adapt educational materials for viral load treatment literacy  Viral load treatment literacy/ messaging materials developed/ Ongoing adapted  Collaborate with OPHID to support site level activities - clinician VL job aids, sample collection and  Uptake of available VL services is optimal Ongoing transport, results retrieval and documentation, data review meetings.  Enhanced treatment literacy training for adherence Outreach Workers and Support Group leaders  Improved capacity of Outreach Workers and Support Group Not Yet leaders to support clients on ART Address the dynamics of stigma, gender and social norms as a means to improve retention  CPFs and Outreach Workers conduct community dialogue sessions to provide support for PLHIV to  No of community dialogue sessions conducted Ongoing practice self-care including remaining in long term treatment  Orient the CPFs and the Outreach Workers in the use of in FHI 360’s C-Change’s Model to improve  No of CPFs and Outreach Workers oriented on the C-Change Not Done adherence retention and viral load suppression Model  Disclosure support for the PLHIV through family conferencing Ongoing  PLHIV supported in practicing self-care which will be adapted to meet different literacy levels Ongoing Provide differentiated care and support for adolescent girls and young women  Identify and utilize community support networks for young people  Networks including social media platforms identified and Not Yet operationalised  Identify and adapt appropriate approaches/ models currently in use to mobilise young women,  Models/ approaches identified and adapted Ongoing adolescents and men, e.g. ZVANDIRI, Join In Circuit, Male Mobilisers, SAYWHAT  Mentor young women as role models to provide other young women with positive support in treatment  Mentors matched with mentees Not Yet care and retention.

October 1, 2015 – September, 30 2016 | Year 1 Annual Progress Report 31

 Engage schools and communities through Sport as an entry point for delivering messages on self-care  Sporting events for delivery of self-care messages Not Yet  Facilitate and support peer-led community dialogues for adolescents, men and young women to promote  No. of community dialogues held with target populations Ongoing age specific issues related to treatment, positive norms and behaviours among their peers  Identify expert patients to provide youth friendly and age and gender specific treatment, care and  No. of expert patients identified and providing support services Done retention support services Strengthen M&E system for HIV care and treatment at community level  Develop/ adapt community M&E tools for the project (including, referral register, tracking tools,  M&E tools developed/ adapted Done community based appointment register, defaulter tracking register)  Develop/adapt standard operating procedures for the community-based health workers to use for patient  Patient tracking SOPs developed/adapted Done tracking  Orient MEAs, CHOs, CPFs, and CBHWs on data management and data capturing tools  Project staff oriented Done  Submit monthly summary report to MoHCC through their reporting system  Monthly reports submitted to MoHCC Done  Conduct monthly data validation exercises  Verified data available Done  Conduct quarterly DQA exercises  DQA reports shared Done  Conduct monthly data review meetings at district level  Monthly data review meetings held Done  Develop and maintain ZHCT project database  ZHCT project data base developed and utilized Done

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Annex III: List of ZHCT SOPs and Data Collection Tools

1. Attendance Register 2. Capacity Building Register 3. CARG Monitoring Form 4. CARG Register 5. CARG Standard Operating Procedures 6. CARG Summary Register 7. Home-Based HIV Testing Standard Operating Procedures 8. HTS Consent Forms 9. HTS Register 10. Index Case Register 11. Individual Household Follow-Up Form 12. M&E Standard Operating Procedures 13. Monthly Return Form 14. Patient Tracing and Tracking Standard Operating Procedures 15. Patient Tracking Register 16. Referral Daily Tally Sheet 17. Symptom Screening Tool

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