Provic) Year 6 Quarter 1 Report

DRC INTEGRATED

HIV/AIDS PROJECT

PROJET INTEGRE DE VIH/SIDA AU CONGO (PROVIC) YEAR 6 QUARTER 1 REPORT

October−December 2014 Contract #GHH-I-00-07-00061-00, Order No. 03

Submitted February 27, 2015; Re-submitted April 7, 2015

This document was produced by the ProVIC PATH Consortium through support provided by the United States Agency for International Development, under the terms of Contract No. I-00-07-00061-00. The opinions herein are those of the author(s) and do not necessarily reflect the views of the United States Agency for International Development or the United States government.

TABLE OF CONTENTS

Acronyms and abbreviations ...... iv Executive summary ...... v Section I: Progress by technical component ...... 1 Intermediate Result 1: Continued access to comprehensive PMTCT and HIV prevention interventions for key populations ...... 1 Sub-IR 1.1: Access to comprehensive PMTCT services according to national norms in ProVIC-supported sites ...... 1 Sub-IR 1.2: Promotion and uptake of pediatric counseling and testing, and improvement in follow-up of mother-infant pairs ...... 4 Sub-IR 1.3: Undertaking of prevention strategies for key populations in target areas ...... 6 Activities planned for the next quarter for Intermediate Result 1 ...... 9 Intermediate Result 2: Improved access to adult and pediatric treatment ...... 9 Sub-IR 2.1: Maximizing access to ART ...... 9 Sub-IR 2.2: Maximizing the quality of care and ART services ...... 12 Activities planned for the next quarter for Intermediate Result 2 ...... 16 Intermediate Result 3: Health systems strengthening supported ...... 16 Sub-IR 3.1: Capacity of provincial government health systems supported ...... 16 Sub-IR 3.2: Strategic information systems at facility levels strengthened ...... 17 Activities planned for the next quarter for Intermediate Result 3 ...... 19 Section II. Program management update ...... 20 Administration and finance ...... 20 Grants management ...... 20 Environmental monitoring and mitigation activities ...... 20

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 iii ACRONYMS AND ABBREVIATIONS

AIDS acquired immune deficiency syndrome ART antiretroviral therapy ARV antiretroviral medication CSW commercial sex workers DATIM Data for Accountability, Transparency, and Impact DBS dried blood spot DRC Democratic Republic of Congo E2A Evidence to Action EID early infant diagnosis EMMP Environmental Mitigation and Monitoring Plan FANTA Food and Nutrition Technical Assistance III Project FY Fiscal Year GBV gender-based violence Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria HAART highly active antiretroviral therapy HTC HIV testing and counseling HIV human immunodeficiency virus IDU injection drug user IR Intermediate Result M&E monitoring and evaluation MER Monitoring, Evaluation, and Reporting MOH Ministry of Health MSM men who have sex with men MUAC mid-upper arm circumference NACS nutrition assessment, counseling, and support NGO nongovernmental organization PCR polymerase chain reaction PEPFAR United States President’s Emergency Plan for AIDS Relief PITC provider-initiated testing and counseling PLHIV people living with HIV/AIDS PMTCT prevention of mother-to-child transmission of HIV PNLS Programme National de Lutte contre le SIDA (National HIV/AIDS Program) PNMLS Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (National Multi-Sectorial Program for the Fight against AIDS) PNSR Programme National de Santé de la Reproduction (National Reproductive Health Program) PRONANUT Programme National de Nutrition (Ministry of Health National Nutrition Department) ProVIC Projet Intégré de VIH/SIDA au Congo (Integrated HIV/AIDS Project) QA/QI quality assurance/quality improvement ReCos relais communautaires (community outreach volunteers) SCMS Supply Chain Management System SGBV sexual and gender-based violence STI sexually transmitted infection TB tuberculosis USAID United States Agency for International Development WHO World Health Organization

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 iv EXECUTIVE SUMMARY

The first quarter of Fiscal Year (FY) 2015 was an important transitional quarter for Projet Intégré de VIH/SIDA au Congo (ProVIC). While ProVIC continued to offer its comprehensive package of care, treatment, and support services through 99 supported health facilities, the quarter was also highlighted by the closure of ProVIC’s activities in Bas-Congo, negotiations and agreement with the Programme National de Lutte contre le SIDA (PNLS) on the scale-up of activities in Bunia, and the integration of Tier.net as an antiretroviral therapy (ART) patient monitoring tool.

For several months, ProVIC, the United States Agency for International Development (USAID), and the PNLS (at the national and provincial levels) planned for the withdrawal of ProVIC from Bas- Congo, due to the low prevalence of HIV in the province and the capacity of the Global Fund to Fight AIDS, Tuberculosis and Malaria to absorb ProVIC sites into its program. This allowed ProVIC to shift its resources to Ituri district, Province Orientale, to focus on high-volume health facilities and health zones that have a higher prevalence of HIV. The closure of ProVIC’s Bas-Congo operations was carefully coordinated with the national and provincial governments, Global Fund, health zone offices, and health facilities to ensure a smooth transition, keeping the well-being of beneficiaries at the center of the planning process. In December 2014, after conducting final joint assessments with technical staff from the PNLS and Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (PNMLS) in Bas-Congo, ProVIC sites were formally transferred to local Global Fund partners. This closure was marked by a joint visit from the National PNLS Director, the Deputy Director of the PNMLS, USAID, and the ProVIC Chief of Party, and included a debriefing with the Provincial Minister of Health and the President of the Provincial Assembly.

In parallel with the closure of ProVIC’s operations in Bas-Congo, ProVIC and USAID engaged in detailed planning and negotiations with the national and provincial levels of the PNLS in Province Orientale on ProVIC’s expansion into Ituri district, where ProVIC will expand its coverage from seven health facilities in Bunia Health Zone to 32 health facilities across five health zones, adding Rwampara, Nizi, Bambu, and Mungualu. This shift from low-prevalence Bas-Congo to higher- prevalence health zones in Ituri, which borders Uganda, is part of ProVIC’s ongoing efforts to improve cost efficiencies and continually adapt to the nature of the epidemic in the Democratic Republic of Congo.

ProVIC significantly upgraded its capacity in patient management in Quarter 1 by integrating the Tier.net patient management tool across most ProVIC-supported sites, which included installing Tier.net and training health care providers in more than 80 health facilities in Kinshasa, Katanga, and Orientale. The Tier.net tool will change the way ProVIC collects and analyzes data on its beneficiary cohort, as the tool manages individual patient data which are then aggregated for analysis at the site, health zone, provincial, and national levels. As the PNLS is using this tool nationally, ProVIC’s Tier.net data are standardized and can be aggregated with data from other non-ProVIC and non-US President’s Emergency Plan for AIDS Relief projects. Going forward, considerable emphasis will be placed on working with health zone- and site-level health care providers to use Tier.net data in their analysis and planning.

Prevention of mother-to-child transmission of HIV*

The majority of ProVIC’s beneficiaries receive services through the prevention of mother-to-child transmission of HIV (PMTCT) platform, following ProVIC’s acceleration toward PMTCT in 2012

* All targets and results cited in this report are in reference to targets and results established and expected under the AIDSTAR mechanism under which ProVIC is supported from October 2014 to March 2015, half of the annual fiscal year reporting period.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 v and the Strategic Pivot in 2013. A narrative of the PMTCT cascade is presented and analyzed in detail in Sub-IR 1.1 (page 3).

In Quarter 1, ProVIC tested 15,774 pregnant women, achieving 31% of its established six-month target under the AIDSTAR contract. ProVIC identified 321 HIV positive pregnant women in the first quarter of FY 2015 (2% PMTCT positivity rate), of which 253 (78%) were pregnant women newly identified at health clinics through the PMTCT entry point. Of the 321 HIV positive pregnant women, 284 received antiretroviral medication (ARV) for PMTCT (88%)

HIV testing and counseling

The results of ProVIC’s HIV testing and counseling activities reflect counseling provided at the health facility level to pregnant women and their families and patients identified through PITC, as well as counseling specifically targeting key populations of commercial sex workers (CSW), men who have sex with men (MSM), and injection drug users (IDUs) and priority populations of truck drivers, miners, and fishermen. In total, 24,061 individuals were tested for HIV in Quarter 1, a 39% achievement against the established six-month target, of which 1,038 individuals tested positive, a seropositivity rate of 4%. Seropositivity rates for key and priority populations are listed below: • CSW: 13.4% (97 individuals tested in Katanga and Kinshasa) • MSM: 8.6% (139 individuals tested in Kinshasa) • IDU: 11.11% (18 individuals tested in Kinshasa) • Truck drivers: 12.5% (112 individuals tested in Orientale, Katanga, Kinshasa and Bas Congo) • Miners: 9.4% (203 individuals tested in Katanga and Province Orientale) • Fishermen: 2.1% (95 individuals tested in Katanga and Province Orientale)

Care and support, and treatment

In Quarter 1, 5,036 people living with HIV/AIDS (PLHIV) who are part of ProVIC’s ART cohort (adult and children) received at least one care service. Of the 5,036 PLHIV who received at least one clinical service, 4,925 were screened for tuberculosis (TB). 74 clinically malnourished PLHIV were provided with therapeutic and supplementary food; 2,359 HIV positive adults and children received either a clinical assessment, CD4 count, or viral load test. 427 HIV-infected adults and children were newly enrolled on ART this quarter, of which 158 were HIV positive pregnant women.

In summary, Quarter 1 results represent a consistent extension of the comprehensive HIV/AIDS services offered in ProVIC sites. ProVIC anticipates meeting its established targets across the two funding mechanisms that will support ProVIC in FY 2015—AIDSTAR and Evidence to Action (E2A).

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 vi

SECTION I: PROGRESS BY TECHNICAL COMPONENT

Intermediate Result 1: Continued access to comprehensive PMTCT and HIV prevention interventions for key populations

Sub-IR 1.1: Access to comprehensive PMTCT services according to national norms in ProVIC-supported sites Activities and achievements Activity 1: Access to comprehensive PMTCT services (including Option B+) in ProVIC sites, according to national norms. During the first quarter of Year 6, Projet Intégré de VIH/SIDA au Congo (ProVIC) provided support to 99 sites in four provinces—nine in Kinshasa, 51 in Katanga, 18 in Bas-Congo, and 21 in Province Orientale. Figure 1 shows the distribution of ProVIC-supported health zones and health facilities (hub and spoke sites) across the four ProVIC provinces. ProVIC continues to be one of the main supporters of prevention of mother-to-child transmission of HIV (PMTCT) services in the Democratic Republic of Congo (DRC), and services are Option B+ training in Bunia. provided in accordance with Ministry of Health (MOH) guidelines and 2014 US President’s Emergency Plan for AIDS Relief (PEPFAR) technical recommendations. The 2014 PMTCT Technical Considerations reflected a major shift in PMTCT programming highlighted in the World Health Organization’s (WHO) 2013 Consolidated Guidelines, most significantly that ART should be provided to all HIV-positive pregnant and breastfeeding women regardless of CD4 count (Option B+). ProVIC contributed actively to the implementation of this recommendation by working with the Programme National de Lutte contre le SIDA (PNLS), Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (PNMLS), and MOH to support this critical transition, and all ProVIC-supported sites were implementing Option B+ by the end of Quarter 1.

Figure 1. ProVIC health zones and health facilities, by province, in Q1 FY 2015.

45 39 40 35 30 25

20 16 15 13 12 12 10 5 5 4 4 5 4 5 5 0 Bas-Congo Katanga Kinshasa Orientale

Health zones Hub sites Spoke sites

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 1

In the first quarter, ProVIC implemented the PEPFAR-recommended PMTCT package (taking into account the four pillars of comprehensive PMTCT) in all 99 project-supported health facilities in order to make progress toward reaching the AIDS-free generation goal. This package includes HIV testing for pregnant women and members of their family, uptake of ARVs for HIV-positive persons according to national guidelines, and provision of essential care and support (e.g., family planning, gender-based violence [GBV] screening, TB screening and referral for treatment, sexually transmitted infection [STI] testing and treatment, nutritional evaluation and treatment, and psychosocial support through Mentor Mothers and self-help groups).

In order to continually improve the quality of services offered, a technical focus was placed on each pillar of comprehensive PMTCT. We have highlighted some of these efforts below. • Pillar 1. Primary HIV prevention. ProVIC ensured that both HIV-negative and HIV- positive clients benefited from the prevention package for PMTCT (education on consistent Bunia needs assessment working session at the Nizi Health and correct condom use and Zone office with NACP and ProVIC teams. condom negotiation skills, ensuring an adequate supply of condoms and lubricant, and incorporating Prevention with Positives interventions), as well as encouraged couples counseling and testing. After clinical services, all tested clients were linked to community organizations according to their HIV status (HIV-negative clients continued to receive messages about HIV, and HIV-positive clients were linked to community support groups). Supervision will continue and be maintained throughout Year 6. • Pillar 2. Integration of PMTCT and family planning. Providers used regular repeat visits for antenatal care and HIV care and treatment services as opportunities to provide women and their male partners with family planning counseling and services according to MOH guidelines. These services include counseling on exclusive breastfeeding over the first six months, the lactational amenorrhea method, and modern contraceptives and provision of safe pregnancy counseling for women living with HIV who wish to have children. • Pillar 3. Provision of ART for pregnant, postpartum, and breastfeeding women and infant prophylaxis. This pillar was strengthened through practices such as: † o pre-packaging of ART kits (TDF/3TC/EFV ), cotrimoxazole prophylaxis, and condoms, which providers deliver to women who test HIV-positive; o adherence counseling, which is promoted by Mentor Mothers in areas where the Mentor Mother approach is being implemented; o integration of ART services within maternal and child health clinical sites, with arrangements for the ongoing provision of high-quality HIV care; o encouragement to decentralize the delivery of ART to peripheral health facilities and task- sharing to allow nurses to initiate and maintain ART within the national regulatory framework; and o strengthening of linkages between providers and community actors (Mentor Mothers or other peer counselors) to ensure HIV-positive pregnant and breastfeeding women are adherent and retained in the ART program and to reduce loss to follow-up. • Pillar 4. Essential care for HIV-positive women and children in PMTCT programs. Efforts taken in Year 5 were continued in this quarter. In addition to the HIV prevention and family

† TDF+3TC+EFV: tenofovir, lamivudine, and efavirenz.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 2

planning interventions described previously, ProVIC’s PMTCT program worked with the care and support team to integrate the provision of essential care activities, including provision of cotrimoxazole prophylaxis, TB screening and treatment (if available at the health facility) or referral to another facility, prevention and treatment of syphilis, high-quality antenatal care services and delivery, and nutrition assessment, counseling, and support (NACS). During the first quarter of Fiscal Year (FY) 2015, GBV screening activities and support for survivors/victims of sexual and gender-based violence (SGBV) continued in the 40 ProVIC-supported health facilities that offered PMTCT services (nine in Kinshasa, 17 in Katanga, and 14 in Orientale).

Table 1 presents ProVIC’s achievements on the PMTCT cascade in the first quarter of FY 2015. As illustrated, almost all known newly identified HIV-positive pregnant women were reported as receiving ARVs to reduce the risk of maternal-to-child transmission.

Table 1. PMTCT cascade by province in Q1 FY 2015. Bas-Congo Katanga Kinshasa Orientale Total Pregnant women with known HIV status (includes women who were tested for HIV and received their results) and known positives at entry 2,035 7,432 3,999 2,313 15,774 Known positives at entry 8 42 15 3 68 Number of positives identified 33 146 37 37 253 Total positives 41 188 52 40 321 Seropositivity rate 2.0% 2.5% 1.3% 1.7% 2.0% Known HIV-positive pregnant women who received ARVs (reported) 35 168 47 34 284 HIV-positive women newly initiated on treatment during pregnancy 33 144 43 34 254 HIV-positive women already on treatment at beginning of pregnancy 2 24 4 0 30

Activity 2: Extend/maintain innovative approaches to improve the quality of PMTCT services for pregnant women and their families. ProVIC provided technical assistance in Quarter 1 to improve the quality of services offered, taking into account PEPFAR’s recommendations to maintain 90% of HIV-positive pregnant women in the program, by reinforcing the following strategies. • Mentor Mother approach. Mentor Mother activities were maintained at 22 ProVIC-supported health facilities, and the PMTCT team provided coaching to ensure the high quality of this intervention to support the continuum of care for HIV-positive women and their families. In addition, ProVIC worked with the PNMLS, PNLS, and health zones to develop a plan to expand the Mentor Mother approach to 58 health facilities. Training tools were updated and the expansion will take place in Quarter 2. • Quality assurance/quality improvement (QA/QI) collaborative approach. At the end of Quarter 1, ProVIC worked with the United States Agency for International Development’s (USAID) Applying Science to Strengthen and Improve Systems project to plan for the expansion of the collaborative QA/QI approach to improve the quality of services provided at 30 ProVIC- supported sites (included at the 58 sites targeted in Year 6), with a focus on care and treatment. In addition to PMTCT activities, the following topics will be considered: o retention/adherence; o ART case management; o early infant diagnosis (EID); and o referral and counter-referral.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 3

• Performance-based financing. In collaboration with the MOH, ProVIC continued to use performance-based financing services to coach and monitor activities at Kikimi Hospital Center. As the original performance-based financing model was designed only to account for PMTCT activities, the model will be adapted to incorporate treatment and retention indicators.

Activity 3: Ensure coaching and mentorship for integrated PMTCT care, support, and treatment services offered through the health zones. In Quarter 1, ProVIC used an integrated tool to monitor the quality of PMTCT care, support, and treatment services offered in ProVIC-supported health facilities. ProVIC’s technical team divided project technical staff into teams to carry out quality monitoring at all project sites in ProVIC’s four provinces. This integrated tool assists with the monthly collection of information on implementation across all of ProVIC’s technical components (e.g., PMTCT, GBV, ART, laboratory services), and helps monitor the quality of services provided at several health facilities in a time-efficient manner. Thus, the technical team is better able to plan solutions for challenges and resolve issues faced by providers on the continuum of response.

To improve the provision of support and mentoring available to health facilities, a site supervisor was added in Kamina Health Zone in Katanga, and ProVIC also engaged ten interns to strengthen mentorship in ProVIC-supported sites (two each in Kinshasa, Kisangani, and Bunia, and four in Katanga).

Activity 4: Reinforce the capacity of the DRC government at multiple levels to provide comprehensive PMCTC services and treatment. ProVIC continued to participate in quarterly meetings held by the national PMTCT working group, the Maternal, Newborn, and Child Health Task Force, and the working group to revise the DRC’s National HIV/AIDS Strategic Plan. The PMTCT team has been actively involved in discussions on strengthening national data tools, specifically on Option B+ and pediatric treatment components.

The ProVIC team continued to contribute to the dissemination of national standards and guidelines on maternal, newborn, and child health at supported health facilities. These documents, validated by the MOH, explain standards for all interventions offered to women and infants at all levels of the health care system, as well as standards related to adolescent and youth care, family planning, and care for victims of SGBV.

Sub-IR 1.2: Promotion and uptake of pediatric counseling and testing, and improvement in follow-up of mother-infant pairs Activities and achievements Activity 1: Reinforce the system of early infant testing and services. To improve EID for exposed infants, ProVIC continued and reinforced messages to parents and caregivers during delivery at antenatal care clinics and follow-up visits at under-five clinics on the benefit of EID and needed follow-up for infants born to HIV-positive mothers. Follow-up messaging and reinforcement was also undertaken through use of mobile technology (phone calls and SMS) and home visits by Mentor Mothers to remind mothers of follow-up care visits for infants at 6 weeks for EID and initiation on cotrimoxazole prophylaxis.

Emphasis was placed on strengthening EID of children born to HIV-positive mothers; testing of older children of HIV-positive pregnant and breastfeeding women; testing of children of mothers identified as HIV positive during visits to under-five clinics; tracking and testing of all children and adolescents attending TB clinics and malnutrition centers; and testing of children from families of PLHIV and other children visiting health facilities. Care providers used these multiple entry points to identify HIV-positive children and link them to care and treatment services. ProVIC and PNLS staff also worked closely with nurses during supervision and site visits to ensure that provider-initiated testing and counseling (PITC) was carried out in the above-mentioned entry points.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 4

Dried blood spot (DBS) samples from children exposed to HIV were collected in all ProVIC provinces in Quarter 1. In Katanga, samples from 51 ProVIC-supported health facilities were sent to the Katanga Provincial Reference HIV/AIDS Laboratory for quality control and completion of analysis forms before being shipped to the National PNLS Laboratory in Kinshasa, with support from the United Nations Children’s Fund for sample transport. DBS samples collected in Bas-Congo, Orientale, and Kinshasa were sent directly to the National PNLS Laboratory in Kinshasa. This system allowed the PNLS to directly monitor results and collected data on children exposed to HIV.

In Quarter 1, ProVIC also focused on strengthening the capacity of health care providers to collect DBS samples. A total of 224 health care providers in Katanga, Kinshasa, and Orientale were trained on DBS sample collection and how to correctly complete DNA polymerase chain reaction (PCR) analysis request forms.

ProVIC encountered major delays in the reporting of results from DBS samples this quarter due to adjustments in laboratory locations, installation of an extractor, and failure of the central amplification unit in Kinshasa. Thus far, the National PNLS Laboratory has provided initial results for HIV DNA PCR for 56 DBS samples. Of the 47 samples tested in the first round of PCR, two tested positive, one from Kinshasa and one from Orientale. The ProVIC team followed up with health care providers at each health facility to ensure that these two children were placed on ART. The remaining nine samples in the second round of PCR testing tested negative.

Activity 2: Improve the clinical follow-up of HIV-exposed children, including provision of the essential care package to the newborn baby. ProVIC focused on the clinical follow-up of HIV-exposed children, including provision of the essential care package to the newborn baby; provision of nevirapine syrup at delivery to HIV-exposed infants and cotrimoxazole prophylaxis at 6 weeks of age; and placement of eligible children on ART. HIV-exposed infants also benefited from routine vaccination, nutrition counseling on feeding methods, routine growth monitoring, and EID, in accordance with national guidelines. Table 2 below outlines the breakdown of testing and services provided to infants by province. 151 children born to HIV-positive women were tested within 12 months of birth, which reveals that EID was carried out for 47% of HIV exposed infants—this exceeds ProVIC’s FY2015 target of 45% and also reflects an increase from the 40% achieved in FY2014. However, as depicted in Table 2, there were disparities in EID performance between provinces—Kinshasa’s high achievement (119%) is likely due to the efforts of Mentor Mothers following up with HIV-positive mothers to ensure that their infants were brought in for testing. Additionally, health facilities in Kinshasa did not face the same transportation challenges as health facilities in other provinces, given that the National Laboratory is in Kinshasa. 121 children were started on cotrimoxazole prophylaxis within two months of birth.

Table 2. Testing and services provided to infants, by province, in Q1 FY 2015. Bas-Congo Katanga Kinshasa Orientale Total HIV-positive pregnant women 41 188 52 40 321 Infants who received an HIV test within 12 months of birth 10 53 62 26 151 Percentage of infants receiving EID 24% 28% 119% 65% 47% Infants born to HIV-positive pregnant women who were started on cotrimoxazole prophylaxis within two months of birth 6 38 25 52 121

Challenges during the reporting period and proposed solutions

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 5

Challenges Proposed solutions Delay in receiving results from DNA PCR tests • Set up a clear DNA PCR network, taking into from the National PNLS Laboratory, making it account samples from all sites to the difficult to track and follow up infected laboratory and results back to the sites. children. • Advocate to contract with a private DNA PCR laboratory when the PNLS laboratory fails. • Approach the PNLS about decentralizing DBS analysis. Insufficient staffing to fully support and ensure • Train health workers and strengthen the provision of Option B+ at all sites in the mentoring to ensure that Option B+ is carried three ProVIC-supported provinces. out at all ProVIC-supported health facilities. Low uptake of HIV testing after the first DNA • Reinforce the mentorship of health care PCR as recommended by the PNLS. providers. • Organize a refresher training, focusing on how to boost uptake of infant HIV pediatric care and treatment.

Sub-IR 1.3: Undertaking of prevention strategies for key populations in target areas Activities and achievements Activity 1: Reinforce and expand access to prevention services for key populations and other vulnerable groups. ProVIC provided HIV prevention services to key populations in Quarter 1, including men who have sex with men (MSM) and commercial sex workers (CSW). A total of 308 individuals (232 CSW and 76 MSM) were reached during HIV outreach sessions carried out by peer educators, a 16% achievement against ProVIC’s established six-month target for FY 2015.

In addition to HIV awareness-raising activities, ProVIC tested 254 members of key populations (38% CSW, 55% MSM, and 7% IDU), of whom 27 were revealed to be HIV positive, reflecting a 31% achievement against ProVIC’s six-month target for this activity. Table 3 details the breakdown of individuals from key populations who received HIV testing services through mobile services provided by nongovernmental organization (NGO) World Production and St. Hilaire Health Center, ProVIC’s primary partners offering prevention and testing services to key populations. Delays in finalizing fixed obligation grant agreements with St. Hilaire Health Center and World Production contributed to ProVIC’s low achievement this quarter.

Table 3. Results of key populations tested by province in Q1 FY 2015. Number of individuals tested and their results CSW MSM IDU Province Partner Negative Positive Seropositivity Negative Positive Seropositivity Negative Positive Seropositivity rate rate rate Katanga World Production 33 4 10.8% 0 0 N/A 0 0 N/A Kinshasa St. Hilaire 51 9 15% 127 12 8.6% 16 2 11.11% TOTAL 84 13 13.4% 127 12 8.6% 16 2 11.11%

Katanga World Production is ProVIC’s main partner for carrying out prevention services for key populations in Katanga. The NGO uses peer educators to raise awareness of HIV infection prevention methods and conducts HIV testing and counseling (HTC) sessions for CSW and MSM living in Lubumbashi and Kasumbalesa. Condoms and lubricants are distributed at HIV sensitization sessions. In Quarter 1, individuals were screened for STIs and suspected STI cases were referred to appropriate health facilities for further testing and treatment. ProVIC also used the “hotel-to-hotel” approach to better

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 6

reach CSW with HIV awareness and prevention messaging and HTC services. With agreement from hotel managers, World Production enlisted peer educators and health care providers from local ProVIC- supported health facilities to provide HIV prevention and HTC services at hotels frequented by CSW. Laboratory technicians were on hand to facilitate the provision of HIV test results and health care providers provided referrals to local health facilities for follow- on care and treatment for those Mobile nighttime HTC session in Kisangani. who tested HIV positive. This strategy allowed ProVIC to better reach CSW and increase their use of HTC services. Similarly, HIV sensitization and HTC sessions were held near known MSM hotspots to better reach MSM with services.

Kinshasa ProVIC provides support to an MSM-friendly health facility in Kinshasa, St. Hilaire Health Center, to allow them to provide HIV and STI testing, treatment, care, and support services for key populations, MSM in particular. St. Hilaire also offers testing for TB and some family planning services. St. Hilaire collaborated with staff from Progrès Santé Sans Prix to offer HTC services on World AIDS Day in December 2014.

Province Orientale In addition to support provided by the PNMLS to carry out sensitization activities in Kisangani and Bunia, Neema Health Center worked with relais communautaires (ReCos, community outreach volunteers) to offer HIV sensitization and mobile HTC to key and other vulnerable populations, including CSW, MSM, taxi drivers, bikers, and low-income commercial vendors. Even though champion communities are no longer supported by ProVIC, ReCos and peer educators from the former Neema Champion Community continue to actively disseminate HIV prevention messaging throughout the community.

Activity 2: Mobilize communities around ProVIC-supported health facilities with high prevalence rates to increase demand for and use of services, as well as involvement of male partners. ProVIC accomplished expected objectives for this activity primarily due to advocacy efforts carried out by health facilities supported by ProVIC. HIV sensitization activities, led by peer educators, Mentor Mothers, and ReCos, were carried out in communities in ProVIC-supported health zones. ReCos and Mentor Mothers reached 93,952 members of the general population (including women reached through the PMTCT entry point) with HIV prevention messaging in Quarter 1, including 15,745 men and 78,207 women. Particular emphasis was placed on the involvement of male partners in HIV prevention and infection control.

Activity 3: Reinforce and expand access to HIV prevention services for other clients: TB patients, STI clients, and malnourished and bedridden patients. In all ProVIC-supported health facilities, emphasis was placed on offering PITC for all clients at various entry points, including patients receiving TB, STI, or malnutrition treatment services and those who were hospitalized for internal medicine or pediatric issues.

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Table 4 provides an overview of individuals tested through PITC at non-PMTCT entry points and their test results. The high seropositivity rate of individuals tested through PITC (14.1%) in comparison to the overall seropositivity rate of individuals tested in Quarter 1 from all entry points (4.3%) underscores the importance of PITC at non-PMTCT entry points to identify and treat clients with HIV.

Table 4. Number of individuals tested at non-PMTCT entry points in Q1 FY 2015. HIV test result Client type/Entry point Negative Positive Total tested Percentage Seropositivity rate TB patients 73 33 106 2.6% 31.1% STI patients 214 20 234 5.8% 8.54% Hospitalized patients 3,171 513 3,684 91.6% 13.9% TOTAL 3,458 566 4,024 100% 14.1%

Activity 4: Support health care providers to effectively screen for GBV in the PMTCT setting. A total of 13,819 individuals were screened for SGBV in Quarter 1 (12,765 women and 1,054 men) among pregnant women attending antenatal care, their male partners, and other family members in the targeted sites.

Activity 5: Provide high-quality support services (medical and psychosocial) to SGBV survivors. In all, 144 GBV cases were identified in this reporting period, and 127 individuals were provided with post-GBV care, including medical consultation and psychological evaluation.

Activity 6: Support community actors by integrating key messages on gender and GBV into PMTCT materials. ProVIC conducted outreach on GBV prevention and family planning in Quarter 1, particularly targeting pregnant women and youth of reproductive age, in ProVIC-supported sites, with an emphasis on how to access prevention, care, and support services offered within health facilities. Also emphasized was the importance of male partner support in increasing women’s ability to adhere to treatment, and the contribution of couples HTC to the reduction of HIV-related stigma for women and as an entry point to HIV services for serodiscordant couples. Service providers and ReCos delivered specific messages on SGBV through educational sessions on maternal and child health and nutrition activities at antenatal and under-five clinics. In this quarter, 4,330 individuals were sensitized on GBV/HIV messages (3,535 women and 795 men). This prevention outreach included educational sessions and discussions, door-to-door visits, interpersonal communication led by peer educators, and distribution of condoms during sessions.

Activity 7: Contribute to efforts of government partners to improve the coordination of interventions and stakeholders in the fight against GBV. In Quarter 1, ProVIC provided financial and logistical support to the Programme National de Santé de la Reproduction (PNSR) for supervision of family planning and GBV services provided by ProVIC-supported health facilities in Lubumbashi, Likasi, Sakania, Kapolowe, and Kolwezi. In Kinshasa, ProVIC supported the Ministry of Gender, Family and Children in organizing a workshop aimed at fostering collaboration and operational synergies between the Agence Nationale de Lutte Contre les Violences Faites a la Femme et a la Jeune, NGOs, and relevant associations to better combat violence against women and girls. The workshop allowed for the development of a map of NGOs and associations that worked in particular focus and intervention areas. A referral and counter- referral system was also set up during the meeting.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 8

Lack of medication in health facilities to treat ProVIC should provide health facilities with STIs and other opportunistic infections. sufficient quantities of medication. The high volume of contractual changes As ProVIC will undergo another contractual necessitates revision/amendment of ProVIC’s change in shifting to E2A, ProVIC’s 100+ 100+ contracts by its limited staff. Some delays contracts will need to be revised for the third resulted, specifically with the MSM-friendly time in 12 months. We will start the process St. Hilaire Health Center. earlier to avoid delays.

Activities planned for the next quarter for Intermediate Result 1 Sub-IR 1.2 Sub-IR 1.1 Promotion and uptake of Sub-IR 1.3 Access to comprehensive PMTCT pediatric counseling and testing, Undertaking of prevention services according to national norms and improvement in follow-up of strategies for key populations in in ProVIC-supported sites mother-infant pairs target areas Ensure provision of high-quality Ensure the ongoing supply of Offer prevention services to PITC and PMTCT services, commodities, including key populations. Offer HIV including Option B+, for pregnant laboratory tests for HIV, testing activities in ProVIC- women and their families. injection safety equipment, supported sites, including and supplies to support proper PITC for at-risk groups (i.e., management and disposal of clients suspected of having biomedical waste. TB and STIs, malnourished children, and children of HIV-positive parents). Extend PMTCT/ART activities in Continue collaborating with Organize mobile HTC the 25 new health facilities in the PNLS to improve the EID targeted toward key Bunia, Province Orientale. network. populations and provide quality assurance for integrated HTC. Carry out an evaluation of the Strengthen PITC HIV testing Provide quality support Mentor Mother approach under for infants visiting health services (medical and the leadership of the PNLS. facilities for malnutrition or psychosocial) to SGBV pediatric services. survivors. Reinforce health zone capacity to test and treat HIV-positive children younger than 15 years. Extend the Mentor Mother approach to 36 additional health facilities.

Intermediate Result 2: Improved access to adult and pediatric treatment

Sub-IR 2.1: Maximizing access to ART Activities and achievements Activity 1: Improve the links to ART services for HIV-positive clients at ProVIC-supported sites. In Quarter 1, HIV-positive patients were identified at all entry points, including antenatal care, labor and delivery, maternity hospitals, STI, TB, and malnutrition treatment facilities, and in-patient services at ProVIC-supported sites. ProVIC’s use of PITC at multiple entry points allowed the project to better identify and link HIV-positive patients to care and treatment services. The ProVIC team ensured that providers placed eligible clients on highly active antiretroviral therapy (HAART), and the ProVIC PMTCT/ART team worked with providers to identify all HIV-positive clients at various

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 9

entry points and provide them with ART and care services. ProVIC provided referral and counter- referral tools in all supported sites and supervised health care providers in the completion of these tools. In keeping with the QA/QI approach, ProVIC held monthly meetings with health care providers to monitor links to ART for HIV-positive individuals.

In all, 559 newly identified PLHIV were enrolled in HIV care and treatment services. Among them 427 were eligible and initiated on lifelong ART (see Figure 2 below). The majority of new PLHIV enrolled on HAART were in Katanga (66%), followed by Kinshasa and Orientale respectively with 18% and 13%. Only 14 new PLHIV were enrolled in Bas-Congo, due to the phasing out of ProVIC activities in the province.

Figure 2. Distribution of new PLHIV enrolled on lifelong ART, by province, in Q1 FY 2015.

300 280 (66%)

250

200

150

100 79 (18%) 54 (13%) 50 14 (3%) 0 Bas-Congo Katanga Kinshasa Orientale

Activity 2: Complete pre-ART laboratory analysis and biological follow-up for PLHIV in ProVIC- supported sites. CD4 count In Quarter 1, CD4 counts were provided to PLHIV visiting ProVIC-supported sites, including pregnant women and their male partners. PIMA™ CD4 Analysers located in central (hub) sites were utilized for testing of blood samples from both hub and peripheral (spoke) sites. PLHIV with a CD4 count of less than 500 were placed on ARVs, as were all children younger than 5 years, who were initiated on ARVs regardless of CD4 count, in accordance with national recommendations. HIV- positive pregnant women were initiated on HAART regardless of CD4 count.

Viral load The National PNLS Laboratory started supporting viral load testing for all health facilities in Kinshasa, and in Quarter 1, two ProVIC-supported health facilities in the province (Kikimi Hospital Center and Bolingani Maternity Center) performed 18 viral load tests. Viral load testing at these two facilities began in October 2014 but stopped in November and December due to malfunctioning laboratory equipment, which required repair.

Other biological tests Other biological monitoring tests (e.g., hemoglobin, hepatic, and kidney) performed prior to initiation on treatment and during follow-up visits remained poorly reported for this quarter. The laboratory equipment needed to perform these tests was not available at most ProVIC sites, including hubs, and clients were unable to pay for testing. In Quarter 2, ProVIC will provide support by paying the national or provincial PNLS laboratories directly to ensure that tests are completed.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 10

The Supply Chain Management System (SCMS) project provided three spectrophotometer machines for placement at Kenya General Reference Hospital in Lubumbashi and Mokili Health Center and Ngezi/PNC Health Center in Province Orientale. Laboratory technicians and health care providers will be provided with training on this equipment in Quarter 2.

Figure 3 below provides an overview of laboratory testing provided to newly identified PLHIV in Quarter 1, by province. Health facilities in Kinshasa provided clinical assessments, CD4 counts, or viral load testing for 72% of newly-identified PLHIV, followed by 65% in Bas Congo, 55% in Orientale, and 50% in Katanga.

Figure 3. Number of PLHIV who received a clinical assessment, CD4 count, or viral load testing in Q1 FY 2015, by province.

800 686 700 600 500

400 342 (50%)

300 195 200 107 (55%) 109 79 (72%) 100 48 31 (65%) 0 Katanga Orientale Kinshasa Bas Congo

Newly-identified PLHIV PLHIV provided with clinical assessment, CD4 count or viral load testing

Activity 3: Ensure coaching and mentorship for integrated PMTCT care, support, and treatment services offered through health zones. The continuum of PMTCT care, support, and treatment services is a complex set of interventions that take place at multiple levels of the DRC health care system. It is therefore important to put in place a structure to coordinate all activities. In this quarter, ProVIC used one integrated tool to monitor the quality of all activities offered in ProVIC-supported health facilities. The ProVIC technical team divided project technical staff into teams to conduct quality monitoring at all project sites. Activities are further elaborated upon in Activity 3 in Sub-IR 1.1 (page 4).

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Stockout of pediatric ARVs. • Work closely with ProVIC logistics staff and SCMS to account for and order pediatric ARVs. • Collaborate with Global Fund to Fight AIDS, Tuberculosis and Malaria sites to obtain pediatric ARVs. Facilities lack equipment for both hemotology • Request clarification from PEPFAR or the US and biochemistry testing. Centers for Disease Control and Prevention on the plan for equipment procurement moving forward.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 11

• Pay national or provincial PNLS laboratories directly to ensure that tests are completed.

Sub-IR 2.2: Maximizing the quality of care and ART services Activities and achievements Activity 1: Provide a high-quality package of care services for PLHIV in ProVIC-supported sites. During this period, ProVIC prioritized access to and provision of high-quality care and support services to PLHIV to improve their survivability and quality of life, and consequently reduce the impact of HIV/AIDS. By providing care and support services, ProVIC aims to reduce the occurrence of opportunistic infections and implement a system for monitoring adherence among PLHIV. The package of services provided to PLHIV included provision of cotrimoxazole prophylaxis, TB screening and referral, nutritional screening and referral, and activities to promote retention in care and treatment.

Provision of cotrimoxazole In accordance with PNLS guidelines, 100% of PLHIV who are enrolled in care should be provided with cotrimoxazole to reduce the occurrence of opportunistic infections. ProVIC-supported health facilities are supplied with cotrimoxazole through the SCMS under the control of health zone offices. Health facilities dispense doses of cotrimoxazole for HIV-positive patients after they receive counseling on their HIV status. During supervision visits, ProVIC staff monitored the procurement of cotrimoxazole and made recommendations to improve the storage of cotrimoxazole and recommended dosage for patients. ProVIC staff inform health care providers about the potential side effects of the medication and the importance of early care, and the importance of taking cotrimoxazole remains an important topic of discussion during self-help group meetings, medical appointments, and home visits.

TB screening, diagnosis, and treatment ProVIC continues to strengthen and systematize monthly TB screenings for all PLHIV at ProVIC- supported health facilities. Every point of contact with a PLHIV is also an opportunity to screen for TB and refer suspected cases to health centers for diagnosis, care, and treatment. In Quarter 1, 4,925 PLHIV (3,405 women and 1,520 men) were screened for TB, which represents an achievement rate of 274% against ProVIC’s established six-month target for this indicator (1,796 PLHIV). Figure 4 shows the number of PLHIV screened for TB this quarter, by province. ProVIC’s high achievement in screening PLHIV for TB can be attributed to the systematization of TB screening for all PLHIV who visit health facilities for medical consultations and for those newly diagnosed as HIV positive—prior to this quarter, active screening for TB for all PLHIV was not carried out systematically across all ProVIC-supported health facilities. Frequent monitoring visits to health facilities to strengthen TB screenings also contributed to the high achievement in this area.

Figure 4. PLHIV screened for TB in Q1 FY 2015, by province.

4,000 3,405 3,500 3,000 2,500 2,166 2,000 1,520 1,500 1,026 1,000 344 398 497 500 143 164 187 0 Bas-Congo Katanga Kinshasa Orientale Total Female Male

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In ProVIC-supported health facilities, health care providers have been given TB screening forms to enable monthly screening of PLHIV, and ProVIC will aim to screen 100% of PLHIV who come to health facilities for check-up visits in Quarter 2, in keeping with national standards and PEPFAR guidelines.

Counseling on nutrition In Quarter 1, ProVIC monitored the provision of nutritional support using the NACS approach, and carried out field visits with Programme National de Nutrition (PRONANUT) and the Food and Nutrition Technical Assistance III Project (FANTA). ProVIC noted that significant advances have been made in the offering of nutritional screening for all PLHIV at various entry points using the nutritional scorecard, in comparison to previous years when health care providers did not monitor the nutritional status of PLHIV as closely. The nutritional scorecard is comprised of the following elements: • Weight, height, and mid-upper arm circumference (MUAC) measurements. • Classification of nutritional status (using body mass index for adults and MUAC for children and pregnant women). • Nutrition and food security evaluation. • Benchmarks for severe malnutrition to guide referrals to nutritional units A health care worker conducts a cooking demonstration (unité nutritionnelle thérapeutique for breastfeeding women at Kikimi Hospital Center. ambulatoire/intensive) for follow-up care.

Of the 1,371 PLHIV who visited ProVIC-supported health facilities for medical consultations in Quarter 1, 1,212 (88%) were provided with a nutritional assessment following the NACS approach, and 90 were deemed to be clinically malnourished (7.4% of all PLHIV who received nutritional screening), with 74 clinically-malnourished PLHIV (82%) provided with therapeutic and supplementary food. Figure 5 shows the cascade of nutritional services provided to PLHIV in Quarter 1 at the 20 health facilities briefed on the NACS approach (three each in Kinshasa and Katanga and 14 in Province Orientale).

Figure 5. Cascade of nutritional services provided to PLHIV by province in Q1 FY 2015.

1000 764 764 800 704

Number 600 of 400 321 321 PLHIV 200 127 127 125 19 15 45 57 45 14 14 0 Lubumbashi Kisangani Kinshasa PLHIV who received nutritional screening PLHIV whose nutritional state was correctly classified PLHIV who received nutritional counseling (based on their nutritional state) PLHIV deemed to be clinically malnourished Malnourished PLHIV provided with therapeutic and supplementary food

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To enhance the provision of nutritional support, cooking demonstrations and nutritional advice are offered at self-help group meetings and during home visits; these activities will continue in Quarter 2 to allow ProVIC to continue providing nutritional support to PLHIV. In an effort to improve the quality of nutrition interventions, ProVIC organized two learning sessions on nutrition in December 2014, in Katanga and Kinshasa, with support from FANTA, to provide a forum for health facilities to exchange information, lessons learned, and best practices on the provision of nutritional support.

However, greater efforts need to be made to ensure that all PLHIV are provided with nutritional support and counseling. ProVIC will continue to closely monitor health care providers in Quarter 2 to ensure that all PLHIV who visit health facilities for services are assessed and provided with nutritional support. ProVIC will also expand the NACS approach to other supported health facilities and continue to train health care providers on the use of this approach.

Retention in care and treatment programs Self-help groups, which meet regularly, are a critical element of a broader strategy of improving PLHIV adherence to ART and care regimens. The aim of self-help groups is to allow PLHIV to address their own care and support needs and offer a space for PLHIV to collectively analyze and think through decisions and issues that affect them. Current self-help groups are associated with health facilities and are typically led by Mentor Mothers and include pregnant and breastfeeding women. Since ProVIC phased out community activities, a major challenge is revitalizing community- based self-help groups around ProVIC-supported health facilities to provide peer support spaces for PLHIV identified through non-PMTCT entry points. ProVIC’s approach to revitalizing community- level self-help groups will be to target self-help groups previously established under champion communities; ProVIC will also consider creating self-help groups in areas that do not have existing groups.

Immunizations for children of HIV-positive mothers In Quarter 1, ProVIC focused on ensuring that children born to HIV-positive mothers received immunizations. Health care providers were advised to remind mothers of immunizations during follow-up visits at health facilities, which helped minimize the number of children lost to follow-up.

Activity 2: Ensure ART for PLHIV (both adults and children). According to national protocol, individuals eligible for HAART include all pregnant and breastfeeding women; all patients presenting with WHO clinical Stage III or IV symptoms; all patients younger than 5 years with a CD4 count of less than 500; children younger than 5 years who test HIV positive; and all HIV-positive children 2 years old and younger. In addition, exposed children who test HIV positive by DNA PCR are initiated on HAART.

All eligible PLHIV were identified and initiated on first-line treatment after clinical staging or CD4 count. Priority pregnant women were provided with a combination of TDF+3TC+EFV, and most other eligible patients received AZT+3TC+NVP‡ in accordance with national HAART guidelines. Nevirapine was replaced by efavirenz for patients undergoing TB treatment.

To ensure that all eligible PLHIV were enrolled on ART, the ProVIC technical team continued to promote early initiation of ART in the same health facilities where patients were screened for HIV. Phone calls, home visits, and Mentor Mothers used the appointment agenda to track PLHIV on ART and ensure retention in care. In Quarter 1, 5,036 PLHIV (3,612 females and 1,424 males) with advanced HIV infection were receiving ART, with 427 (332 females and 95 males) newly enrolled on ART in Quarter 1. Figure 6 provides the distribution of total and newly enrolled HIV-positive adults and children on ART, by province.

‡ AZT+3TC+NVP: zidovudine, lamivudine, and nevirapine.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 14

Figure 6. Numbers of PLHIV on ART in Q1 FY 2015, by province. 3,500 2,846 3,000 2,500 2,000 1,500 1,212 1,000 567 411 500 280 14 79 54 0 Bas-Congo Katanga Kinshasa Orientale

PLHIV newly enrolled on ART Total PLHIV on ART

Activity 3: Ensure initial clinical mentoring and follow-up for clients on ART. To ensure adherence to treatment and retention in care, psychosocial support was offered to clients at self-help groups in health facilities and during home visits by Mentor Mothers, peer educators, care providers, and care and social workers. This contact and support helped sensitize PLHIV on the benefits of regular intake of ARVs and the detection of side effects. ProVIC also placed an emphasis on coaching health care providers on mentoring and following up with PLHIV on ART.

In Quarter 1, health care providers at ProVIC sites in Kinshasa, Katanga, and Province Orientale were trained on Tier.net, a new patient tracking database that allows for the collection and storage of individual information for all HIV-positive patients, regardless of ART eligibility status. Using the Tier.net database, the ProVIC team performed monthly cohort analysis of patients in the program, including initial CD4 count, ART cohort, ART regimens for adults and children, and retention. For this quarter, the ART cohort was 5,036 individuals, with an 85% retention rate.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Care and treatment providers are reluctant to Provide refresher trainings to health facility staff manage pediatric ARVs, so they transfer HIV- on care and treatment for better management of positive children to other facilities. patients regardless of age. Nutrition screening, counseling, and care are • Organize regular visits to health facilities not provided to all PLHIV who visit health trained in the NACS approach to monitor the facilities for treatment. provision of nutrition services to PLHIV. • Brief health care providers in health facilities that have not yet adopted the NACS approach on the essential elements of the approach, and provide materials and nutrition tracking sheets. • Organize joint supervision visits with PRONANUT to more quickly address any issues. Existing self-help groups at health facilities Revitalize community-based self-help groups by: tend to cater to PLHIV identified through o Identifying groups that are still functional. PMTCT entry points, and PLHIV identified o Supporting health zone offices to revitalize through non-PMTCT entry points do not have groups. peer support spaces available to help them work through issues in order to remain adherent to treatment regimens and be retained in care.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 15

Activities planned for the next quarter for Intermediate Result 2 Sub-IR 2.1 Sub-IR 2.2 Maximizing access to ART Maximizing the quality of care and ART services Reinforce PITC at all entry points to maximize Organize refresher trainings for health facility the number of identified HIV-positive clients and staff on care and treatment for better then those initiating HAART. management of patients regardless of age. Train laboratory technicians and health care Identify and revitalize community-level self- providers in Kenya General Reference Hospital, help groups through health zone community Mokili Health Center, and Ngezi/PNC Health outreach workers. Center on using spectrophotometer machines. Reinforce the capacity of ProVIC staff, including site supervisors, on Tier.net cohort analysis. Follow up with FANTA to implement the NACS approach in pilot sites in Bunia and Kisangani.

Intermediate Result 3: Health systems strengthening supported

Sub-IR 3.1: Capacity of provincial government health systems supported Activities and achievements Activity 1: Strengthen the referral and counter-referral system. Referrals to other health facilities are primarily given for patients to get laboratory tests and CD4 counts at hub sites, and for confirmation of diagnosis for suspected cases of TB. ProVIC worked with appropriate governmental health units to improve their capacity to carry out their supervision, coordination, and communication responsibilities.

Activity 2: Support the government’s supervisory role at all levels. ProVIC continued to provide support to the government to improve their supervision of health facilities and Supervision visit, Kingasani Hospital Center, individual service providers at the national, provincial, and Kinshasa. health zone levels. ProVIC also conducted site visits to provide assistance and support to health facilities and to ensure that health care providers complied with applicable standards and guidelines. Table 5 details the types of supervision activities carried out in each ProVIC province.

Table 5. Types of supervision activities by province. Activities Frequency Provinces Joint supervision visits with the PNLS, PNSR, and ProVIC Quarterly Katanga Data validation reviews by the PNLS Quarterly Kinshasa Quarterly reviews Quarterly Katanga and Orientale Supervision site visits Monthly All provinces (health zone level)

Activity 3: Support functioning mechanisms in health zones.

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ProVIC supported 28 health zones in Quarter 1 by providing funds to carry out technical and coordination functions and to purchase supplies and services, such as Internet access, that allow health zones to perform their functions. Additionally, monthly monitoring meetings with all ProVIC- supported health facilities and health care providers were organized in each health zone to monitor the quality of service delivery. During the meetings, general health and HIV data were analyzed and validated; and providers noted constraints and difficulties they faced in implementation, which were discussed and solutions proposed, and shared positive experiences to serve as models or best practices for other providers to improve the quality of services. Issues and questions on the referral and counter- referral process were also discussed. Table 6 outlines the number of providers trained in Quarter 1, by topic area.

Table 6. Number of providers trained in Q1 FY 2015, by topic area. Training topic Number of providers trained Laboratory services to improve the quality of PITC; rapid HIV testing; quality 227 (107 women and 120 men) assurance; external quality assessment (dried tube specimens, DBS); biomedical waste management New Option B+ protocol 95 (39 women and 56 men) Tier.net 89 (25 women and 64 men)

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Low availability of PIMA™ CD4 Analysers. Advocate to the PNLS to recover and refurbish unused machines and place the machines in spoke sites.

Sub-IR 3.2: Strategic information systems at facility levels strengthened Activities and achievements Activity 1: Provide technical monitoring and evaluation (M&E) assistance to the PNMLS and PNLS at the national and provincial levels. In order to improve the quality of reporting from ProVIC implementing partners, the project will support workshops to train health care providers on the use of data collection tools, in response to recommendations made during M&E site visits to health facilities. This training will be led by the PNLS, with technical and financial support from ProVIC.

Activity 2: Provide ongoing datacard and technical support to local partners to improve M&E reporting. The M&E team supervised health care providers at implementing partner sites on their use of data collection tools. Data clerks were used for data entry in some health facilities to improve the completeness, accuracy, and timeliness of datacard submissions. ProVIC provided financial incentives to these data clerks for their assistance. The M&E team also carried out trainings in Kinshasa on the use of Tier.net, and data for treatment indicators were captured using the Tier.net system.

ProVIC’s M&E team received assistance from PATH’s central M&E and information technology teams to reconceptualize and reengineer the ProVIC datacard; plan for improvements to ProVIC’s data uploader; and begin work to better align ProVIC’s reporting system to PEPFAR Monitoring, Evaluation, and Reporting (MER) indicators. In Katanga, 34 M&E contacts and six data clerks were briefed on ProVIC’s new datacard (see Table 7), and data clerks will provide assistance to all sites that have difficulty submitting datacards on time.

Table 7. Distribution of individuals trained in use of the new datacard in Q1 FY 2015. Health zone Facility # Comments Lubumbashi

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Health zone Facility # Comments Lubumbashi Sendwe General Reference 2 Hospital St. Marcel Health Center 2 Kenya Kenya General Reference Hospital 3 Data entry for entire health zone done by data clerk Awadi Health Center 1 Data entry for entire health zone done by data clerk Ruashi Sion Health Center 4 Yambala Health Center 2 Kampemba Marie Elmer Health Center 1 Data entry for entire health zone done by data clerk Kamalondo World Production 2 Likasi Kikula Kalulwa Health Center 2 Uzima Wetu Kikula Health Center 2 Moriah Health Center 2 Mlinzi Health Center 1 Data entry for entire health zone done by data clerk Panda Panda General Reference Hospital 1 Data entry for entire health zone done by data clerk Kapolowe Ndakata Health Center 2 Katanga Health Center 1 Data entry for entire health zone done by data clerk Kolwezi Dilala Uzima Wetu Dilala Health Center 2 Manika Chisambu Health Center 2 Kongolo Medical Reference Center 2 Sakania Sakania Mokambo Health Center 1 Tshisenda Health Center 1 Kitotwe Health Center 1 Buafano Health Center 2 Kasumbalesa Health Center 1 TOTAL 40

Activity 3: Reinforce partners’ M&E capacity through regular monitoring, routine data quality assessment, and internal audits. In Quarter 1, ProVIC’s M&E team provided support and feedback to implementing partners on data collection and verification of monthly datacards. ProVIC’s National M&E Assistant attended and participated in PEPFAR’s Data for Accountability, Transparency, and Impact (DATIM) training of trainers in December 2014, and gained an understanding of the DATIM system, data entry, and analysis; general principles of DATIM; and how to deliver DATIM trainings. ProVIC technical and M&E staff will attend in-country PEPFAR trainings on the DATIM system in February 2015, and DATIM will be operational by the end of Quarter 2.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Ongoing transition of health care providers Provide a briefing on the M&E reporting system trained on M&E and datacard use out of health and datacards at the facility level so multiple facilities, which requires ProVIC to constantly health care providers are trained. identify new contacts and provide briefings on the M&E reporting system and datacards.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 18

Challenges Proposed solutions Delayed submission of monthly datacards by Use of local data clerks to provide assistance to some health facilities due to various reasons, health facilities in data collection and reporting, including network connectivity issues, with additional assistance provided by ProVIC’s transition of health care providers, and delays M&E team as needed. in processing grant agreements. Specific information is needed to accurately Train staff in health facilities in use of HIV data and completely report on HIV activities collection tools. supported at the health facility level, but data collection tools are not used or completed appropriately by facilities, and as a result, reporting is of poor quality. Inadequate number of provincial M&E staff Hire one new M&E assistant per province to given the number of health facilities supported support rollout and supervision of new PEPFAR and the size of health zones. data collection tools, such as DATIM.

Delays in partners’ use of new datacards and Contract with Vera Solutions in order to adapt needed updates to ProVIC’s online M&E and move forward with the new data reporting database. system.

Activities planned for the next quarter for Intermediate Result 3 Sub-IR 3.2 Strategic information systems at facility levels strengthened Complete the first round of data quality assessments in ProVIC-supported health facilities, including in Kapolowe and Kolwezi Health Zones in Katanga. Train all ProVIC-supported health facilities in using the new datacards and data collection tools aligned with PEPFAR MER indicators. Provide technical assistance on M&E to the provincial-level PNMLS and PNLS.

PROVIC YEAR 6 QUARTER 1 REPORT OCTOBER–DECEMBER 2014 19

SECTION II. PROGRAM MANAGEMENT UPDATE

Administration and finance

ProVIC undertook the following key administrative activities in Quarter 1: • Moved its Orientale provincial office to a different location in Kisangani, due to ongoing issues with electricity at the previous location. • Held a refresher training for the Katanga office on compliance with PATH policies and procedures and recommendations from USAID audits. • Conducted a PATH internal audit from November through December 2014.

Human resources Over the past few months, ProVIC has experienced significant staff turnover as offices closed, staff left for positions on other projects, or staff left for promotions to high-level positions at other NGOs or donors. During the no-cost extension period, ProVIC was only able to offer short-term consultant contracts to some staff, but these staff were transitioned to full-time positions in September 2014 with the award of the cost extension.

Grants management

All collaborative accords with health facilities in Bas-Congo ended in November 2014, as part of the process of phasing out Bas-Congo and the transition of beneficiaries to the Global Fund. All Bas- Congo sites were provided with extra stocks of medical supplies, commodities, and HIV tests to carry them through the transition period. Fixed obligation grants and collaborative accords for other provinces were also processed, with some delays due to the high administrative burden of transitioning grant agreements through the no-cost and cost extension periods, which entailed the revision of more than 100 agreements.

Environmental monitoring and mitigation activities

Throughout Q1 of Year 6, ProVIC continued to provide quality assurance and required materials, equipment, and assistance to support comprehensive biomedical waste management in all supported sites. ProVIC and its partners conducted periodic checks of the project’s adherence to the Environmental Mitigation and Monitoring Plan (EMMP) during integrated supervision visits to each site. During these visits, project staff used a checklist to monitor and verify the quality of all activities. This checklist includes a specific section for tracking environmental mitigation and monitoring activities in line with USAID’s health care waste management guidelines and national norms. Through supervision visits, ProVIC has ensured that service providers in supported sites follow the EMMP and respect mutually agreed-upon divisions of roles and responsibilities. ProVIC staff conduct regular supervision visits to each site.

Each site received at least two supervision visits from ProVIC technical staff in Q1, covering biomedical waste management, with the exception of Kamina. Kamina is a new site that is a two-day trip outside of Lubumbashi. In order to give site staff time to put strong procedures and systems in place, as well as minimize travel costs, ProVIC was able to conduct only one supervision visit to Kamina in Q1. The project also organizes supervision visits conducted by health zone staff as well as the PNLS. Each site receives one health zone supervision visit per month and one PNLS supervision visit per quarter.

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In Kinshasa, Katanga, Bas-Congo (for the final time), and Province Orientale, ProVIC continued to supply biomedical waste management supplies to ensure proper handling, sorting, collection, transportation, and disposal of biomedical waste. All sites received a biomedical waste management kit containing a minimum supply of the following consumable and reusable waste management materials: Single-use needles and tubes Rubber boots Brooms and brushes Latex gloves Rubbing alcohol Mops Trash cans Bleach Shovels Sharps disposal containers Trash bags Detergents Rubber gloves Dustpans Wheelbarrows Rubber aprons Hoes Masks

During the supervision visits, ProVIC staff assessed that there was an overall improvement in the management of biomedical waste across the production, incineration, and disposal stages, as well as in the availability of supplies. ProVIC will continue promoting the importance of biomedical waste management by involving site managers in establishing committees for biomedical waste management in Quarter 2.

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