Usaid Zimbabwe Dreams /Game Changer Py6q2

LEADERSHIP, MANAGEMENT AND GOVERNANCE PROJECT SOUTHERN AFRICA

QUARTERLY REPORT

DREAMS /GAME CHANGER PROJECT

PY6Q2 JANUARY-MARCH 2017

The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Africaid acknowledges BMSF, CBM, CPF donors, ELMA, EJAF, JSI, MSH, Maruva Trust, PATA, PEPFAR, SAT, UNAIDS, UNICEF, USAID, and WHO for funding the organization’s programs.

Contents

Acronyms ...... 4

INTRODUCTION AND EXECUTIVE SUMMARY ...... 5

BACKGROUND ...... 7

PLANNED AND ACCOMPLISHED ACTIVITIES IN Q2 ...... 8 Game Changer ...... 8 CATS provide differentiated care and support to 13,030 unique CAYPLHIV in Q2 and a cumulative 19,642 CAYPLHIV ...... 8 Increase in quality of HTS, HIV treatment and care services, and other sexual and reproductive health (SRH) services provided to children, adolescents, and young people...... 9 Africaid drives movement towards elimination of mother-to-child transmission (EMTCT) with engagement of 318 dyads of exposed babies and HIV positive mothers ...... 10 Performance Data ...... 12 Featured Closer Look ...... 13 MK’s Second Chance ...... 13 DREAMS ...... 14 Stakeholder engagement for improved coordination of DREAMS activities ...... 15 16,234 community members mobilized for HTS ...... 15 182 health workers supported through mentorship ...... 15 Performance Data ...... 15 Featured Closer Look ...... 18 USAID Visit to Gweru ...... 18 Africaid Capacity Improvements ...... 18 Improved M&E capacity of CATS ...... 18 Zvandiri Database roll-out ...... 18 Grant management and capacity development support ...... 19 Challenges, Solutions, and Lessons Learned ...... 19 The Way Forward ...... 21

Acronyms AGYW Adolescent girls and young women AIDS Acquired Immunodeficiency Syndrome ALHIV Adolescents living with HIV ART Anti-retroviral therapy ASRH Adolescent and Sexual Reproductive Health CATS Community Adolescent Treatment Supporters CAYPLHIV Children, Adolescents, and Young People Living with HIV CBO Community-based organization CSO Civil society organization DBS Dried blood spot test DREAMS Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe EID Early Infant Diagnosis EMTCT Elimination of mother-to-child transmission GC Game Changer

HTC HIV testing and counseling HTS HIV testing services M&E Monitoring and evaluation MoHCC Ministry of Health and Child Care MOU Memorandum of Understanding MSH Management Sciences for Health NAC National AIDS Council PMTCT Prevention of mother-to-child transmission PSI Population Services International PVO Private Voluntary Organization SRH Sexual and reproductive health TB Tuberculosis USG US Government

INTRODUCTION AND EXECUTIVE SUMMARY

The following document is the Leadership Management and Governance (LMG) DREAMS and Game Changer (GC) Zimbabwe quarterly report covering the period January to March 2017. During this period LMG continued to provide Africaid with funding through a USAID cost reimbursable grant to implement adolescent-responsive HIV prevention, treatment, care and support programmes. MSH has also issued Modification #4 to this USAID cost reimbursable grant in order to increase the obligation and extend the period of performance to sustain the organization’s growth and expansion as well as facilitate additional experience in grant management.

LMG support to strengthen Africaid’s capacity to deliver their services in a manner that aligns with USAID policy and procedures, has been limited to support to grant management. In addition to this, LMG provided support to M&E with a focus on report writing, data collection and analysis.

During quarter two, Africaid’s work consisted of transforming from the planning and set up process of quarter one to an operational program, successfully providing care and support to children, adolescents, and young people living with HIV (CAYPLHIV). During this quarter, Africaid observed significant evidence showing the Zvandiri Community Adolescent Treatment Supporters’ (CATS) improved reach when offering quality adherence counselling, monitoring of their beneficiaries, and home visits to their peers. The district team and head office team mentored health care workers and CATS, ensuring quality management, monitoring, and support. Although Africaid experienced some external challenges during the reporting quarter, the teams managed to successfully implement most of the planned activities with support from key district partners, who were instrumental in ensuring that Africaid’s work is accomplished.

Key Achievements in Quarter Two (January–March 2017):

1. All 24 districts started quarter two (Q2) with protocols and inception meetings completed, memoranda of understanding (MOUs) in place, offices set up, and a foundation of collaboration started with the District Administrators, District Nursing Officers, Rural District Council CEOs, District AIDS Coordinators, ITECH, community leaders, local NGOs, and other relevant key line ministries.

2. A total of 643 trained and mentored CATS actively provided care and support to beneficiaries within 260 facilities and surrounding communities.

3. Increased formation and attendance at support groups in 22 districts: 189 unique support groups met and discussed adherence, viral suppression, ART, and other topics, and 2,355 CAYPLHIV attended of the 10,765 currently on ARV treatment (Target - 43,082), the majority of whom were 10-19 years old. Africaid facilitated some support groups in conjunction with the National AIDS Council (NAC) and other partners, who provided transport funding and refreshments to participants.

4. Africaid prioritized a program focus on CATS’ engagement with mother-baby dyads by providing enhanced care to HIV positive young mothers and their exposed infants. CATS reached a total of 318 individuals, which was 93 percent of the quarterly target and 33% of the annual

target. This engagement increases the number of infants receiving early infant diagnosis (EID) testing, mothers knowing the baby’s results, and prevention of mother-to-child transmission (PMTCT) final outcome after 18 months.

5. CATS provided 13,030 CAYPLHIV across 24 districts with differentiated care during the months of January–March 2017 (achieving 66 percent of the quarter two target). A total of 19,597 CAYPLHIV have received care and support since the start of the program (65 percent achievement of quarterly target and 30% of the annual target).

Challenges and lessons learned:

Quarter two marked the end of the establishment of set up and protocols and the beginning of full- scale operation. While Africaid worked at capacity to complete trainings, recruit staff and complete district preparation, other factors hindered the on-the-ground achievements and productivity of the CATS and staff. Significant challenges faced by the 24 districts affected varied aspects of the program and achievement of targets.

• Limited access to funding and cash precluded activities such as CATS coordination meetings, purchase of bicycles, and visibility materials. • A lack of program vehicles severely limited the mobility of the district teams, thereby rendering mentorship very challenging. • The changing political environment means that Africaid must plan with care and follow additional protocols, occasionally requiring additional time and funding, in order to proceed with necessary activities. • Natural disasters such as flooding caused by heavy rains and storms left many CATS in situations where they could not cross rivers or pass damaged roads to work at health facilities or conduct home visits. • The attrition rate of CATS was surprisingly high in quarter two, severely affecting the program and leaving high-volume facilities with an insufficient number of CATS and some facilities with none. Africaid will look for reasons to explain the unexpected attrition and work towards reengagement. • Underachievement in Afri_Tr_New requires concrete collaboration and planning with partners and stakeholders as well as a focus on index case findings in order to improve reach.

The Way Forward:

Critical results and gap analysis is required in order to accurately assess the situation on the ground and plan the best way forward. Acknowledgement and recognition of best practices and the most successful planning and programming will be shared and replicated in other districts. Collaboration between the Ministry of Health and Child Care (MoHCC), partners, and other key stakeholders is imperative to successful forward movement in quarter three (Q3).

BACKGROUND

Africaid is a local private voluntary organization (PVO Vision: That HIV positive children and 09/2007) that, through its Zvandiri model, provides HIV young people have the knowledge, skills prevention, treatment, care and support for children, and confidence to live happy, healthy, adolescents, and young people with HIV. The Zvandiri fulfilled lives and to pursue their hopes program is committed to helping HIV positive children, and dreams adolescents, and young people to develop the Mission: To increase access to quality care knowledge, skills, and confidence to cope with their HIV and support for HIV positive children and status and to live happy, healthy, safe, and fulfilled lives. young people through the development and dissemination of innovative models of Zvandiri supports the MoHCC in the provision of holistic community-based care and support. care through combined health services, community outreach, psychosocial support and protection services, capacity strengthening programs, and advocacy initiatives. At the forefront of Zvandiri services are young people with HIV who are trained as Community Adolescent Treatment Supporters (CATS). CATS work between the homes and health facilities to support children and young people in need of HIV services, with the aim of improving uptake of HIV testing services (HTS), linkage, and retention in care.

Strategic Objectives: • Service delivery in 27 districts across Zimbabwe: to improve outcomes for HIV positive children, adolescents, and young people throughout the HIV care cascade, to increase capacity of HIV positive children and adolescents to participate meaningfully as service providers for their HIV positive peers, and to increase capacity of families and communities to provide safe, supportive environments for HIV positive children and adolescents. • Capacity strengthening: to enhance the capacity of government sectors and partner organizations within Zimbabwe and the region to provide integrated, quality health, protection, and psychosocial support services through implementation of the Zvandiri model, to improve outcomes for CAYPLHIV through the HIV care cascade, to replicate good practices identified through the Zvandiri Program, and to share lessons learned and experiences around quality HIV service delivery for CAYPLHIV. • Knowledge sharing and advocacy: to improve children’s agency, to reduce stigma, to improve family support, communications and parenting, to increase multi-sectoral awareness of the needs of CAYPLHIV, and to improve child- and adolescent-friendly policies and services. • Collating and dissemination evidence: to improve policies and service delivery as a result of evidence, and to inform quality HIV services for children, adolescents, and young people • Strengthening Africaid’s organizational capacity: to ensure robust policies, procedures, and systems are in place to ensure compliance with the laws of Zimbabwe, and of funding and technical partners; to ensure adequate resources are secured to support implementation of the plan; and to have skilled, competent, and well-resourced staff and volunteers who are able to effectively fulfil their roles and responsibilities.

PLANNED AND ACCOMPLISHED ACTIVITIES IN Q2

Game Changer “Zvandiri” is an existing model of community-based HIV prevention, treatment, care and support for children, adolescents and young people with HIV (CAYPLHIV). Africaid aims to promote the goals of the Game Changer and complement the public health sector as part of the multi-sectoral

Africaid has a distinct, ‘game-changing,’ short-term project with the potential to have an outsize, transformative influence on achieving sustainable epidemic control: the introduction of CATS within 27 priority districts of Zimbabwe.

CATS provide differentiated care and support to 13,030 unique CAYPLHIV in Q2 and a cumulative 19,642 CAYPLHIV With protocols and inceptions completed in Q1, during Q2 Africaid had to opportunity to complete concrete game changing activities that expanded service delivery across 24 districts in Zimbabwe. Through their work in 260 facilities and surrounding communities, 643 CATS provided differentiated care to 13,030 CAYPLHIV in Q2. Differentiated Care Refresher Training for Harare, Seke, and Chitungwiza Differentiated service delivery relies upon the skills and knowledge of the trained CATS. The first step is for the CATS to “Committing suicide, self-stigmatization, refusing to receive psychosocial counselling from the eat, unable to interact with other young people and Africaid team, to share their stories, and to hopeless for my future was the greatest confusion accept themselves as they are. Without a in my past life. However, the Zvandiri program, strong sense of self and foundation, it is through motivation by other young people like me, extremely difficult and overwhelming for a has brought life in me again, and l am ready to CATS to provide care and support to so empower other HIV-positive young children.” — many others in need. The Africaid team is Makonde CATS committed to first and foremost “I forgive my parents for my HIV status.”— supporting the program’s CATS, in health facilities, during home visits, and during Mutare CATS CATS coordination meetings.

As the CATS gain confidence, knowledge, and strength, they are better equipped to understand the personal circumstances and home situations of their beneficiaries, build relationships with them, and assess their individual needs and required levels of care.

Increase in quality of HTS, HIV treatment and care services, and other sexual and reproductive health (SRH) services provided to children, adolescents, and young people As Africaid provides continued mentorship to CATS and health care workers, more beneficiaries are actively referred, supported, and have subsequent improvements in psychosocial well-being and adherence. During Q2, 174 health care workers from 112 facilities received mentorship focusing on agreed upon action points. This capacity building leads to adolescent-friendly facilities with adolescent-friendly hours, active CATS, functional support groups, and access to viral load testing.

Through the care, support, and linkages provided by the CATS, 1,196 CAYPLHIV attended support groups in 82 facilities/communities in 12 districts during Q2. These support groups focused on shared topics such as: “Getting to know me,” “Dig deep, Find me,” adherence counselling, ARTs, and viral suppression. “I always thought that being HIV positive is the greatest curse from God and my spirit medium where nobody loves me and does not even want to interact with me at school, in the community, and household until the day l met my friends from Zvandiri.”—Beneficiary in Mt. Darwin

“Ukuhlangana labanye abafana lami kusimo sabo kuyangenza ngizwe ngikhululekile njalo sengilabangani abatsha.” (“Meeting with others who are like me makes me comfortable and has helped me make friends.”) —Beneficiary Mentorship visits in Mt. Darwin and at Huwana Clinic in in Bulilima Bulilima (left to right)

Support groups are a time for learning, loving, and playing. Young people enjoying games during a support group meeting in Bulawayo.

Africaid drives movement towards elimination of mother-to-child transmission (EMTCT) with engagement of 318 dyads of exposed babies and HIV positive mothers Africaid places CATS at varied entry points (PMTCT) in 73 individual health facilities, providing opportunities for linkage and engagement with young pregnant women and mothers.

• Young pregnant women receive enhanced care from the CATS and Zvandiri district team, including adherence counselling, access to viral load monitoring, home visits, clinical reminders, psychosocial support, and linkage to support groups/young mother support groups. • Young women with breastfeeding children also receive enhanced care from CATS and the Zvandiri Mentor/Intern focusing on the above services as well as focused counselling on nutrition, breastfeeding, and EID testing and results. • The PMTCT final outcome of each dyad is measured at 18 months, or at the cessation of Support group meeting in Gutu breastfeeding, at which point the baby has a final HIV test result. • Enhanced care to these vulnerable young women and exposed babies contributes to Zimbabwe’s national plan for EMTCT. • During Q2, Africaid invested in the initiation of support groups focused on young mothers. During this quarter, Zvimba formed a young mothers’ support group that meets on a monthly basis. In Buhera, three of the six supported clinics have established young mothers’ groups. Harare, Seke, and Chitungwiza have vibrant young mothers’ groups with 30 long- standing participants who meet on a monthly basis. With the dedication and investment of the matron at Concession Hospital in Mazowe, a young mothers’ support group started in February, 2017. Goromonzi also offers support group meetings specific to the needs and interests of a group of young mothers and their babies. Mazowe Case Study

Sibo is a 21-year-old HIV positive young woman and mother to Maria, an 8-week-old baby. Maria’s dried blood spot (DBS) test confirmed her HIV positive status. Maria was newly initiated on anti-retroviral therapy (ART), but unfortunately the first-line ART regimen caused a side effect of severe anemia. Sibo switched to Abacavir and other second-line ART drugs.

The midwife in the PMTCT department at Concession Hospital stated that PMTCT was unsuccessful because A CATS in Chakari Clinic in Kadoma utilizes the Our Story game to provide vital counselling to a 10 young mother

Sibo was hesitant to initiate ART during her pregnancy. The midwife reported that Sibo skipped her review dates when the staff tried to force her to take ART. Unfortunately, Maria’s mother only accepted ART when she realized that she had given birth to a sick baby. Sibo felt bad for not embracing PMTCT and when she eventually started ART she said, “I thought my baby would die.”

Sibo linked to the CATS for counselling and psychosocial support after the realization that her baby was HIV positive. Maria and Sibo are now receiving enhanced care from the CATS, Zvandiri Mentor, and health care workers at Concession Hospital. This multisectorial approach (MoHCC and Africaid) ensures proper adherence for both the nursing mom and her breastfeeding baby.

Table 1: Summary Game Changer Performance

Game Changer FY 17 Q1 Reach 1st Q2 Reach 2nd Annual Donor Funding Q1 FY17 Q1 Total Q2 FY17 Q2 Total Annual % Area in Cascade Project Indicator Annual Quarter Quarter Cummulative Partner Targets Reach Targets Reach Reach Code Target Oct Nov Dec % Reach Jan Feb Mar % Reach Reach

I-TECH 38480 5772 1381 2527 685 4593 80% 11544 2308 2780 1547 6635 57% 11228 29% 3rd 90 (UNAIDS) AFR_CS_COMM USAID 27800 4170 556 258 1205 2019 48% 8340 1292 2356 2702 6350 76% 8369 30% TOTAL 66280 9942 1937 2785 1890 6612 67% 19884 3600 5136 4249 12985 65% 19597 30% I-TECH 9620 1443 9 18 17 44 3% 2886 181 224 93 498 17% 542 6%

2nd 90 (UNAIDS) AFR_TR_NEW USAID 6950 1043 0 0 38 38 4% 2085 63 176 32 271 13% 309 4% TOTAL 16570 2486 9 18 55 82 3% 4971 244 400 125 769 15% 851 5%

I-TECH 25012 3752 1381 2505 670 4556 121% 7503 1953 2398 1469 5820 78% 10376 41%

2nd 90 (UNAIDS) AFR_TR_CURR USAID 18070 2711 0 257 1204 1461 54% 5422 1030 1848 2067 4945 91% 6406 35% 16782 TOTAL 43082 6463 1381 2762 1874 6017 93% 12925 2983 4246 3536 10765 83% 38%

HTS_TST_TA I-TECH 1154 173 0 333 0 333 192% 347 0 35 34 69 20% 402 35% (Index Case 1st 90 (UNAIDS) Finding-3% of USAID 834 125 0 0 0 0 0% 250 0 33 25 58 23% 58 7% AFR_CS_COMM) TOTAL 1988 298 0 333 0 333 112% 597 0 68 59 127 21% 460 21%

I-TECH 30784 4618 0 0 29 29 1% 9235 52 628 235 915 10% 944 3% REF_NEW (80% Referrals 963 Care Comm) USAID 22240 3336 0 0 10 10 0% 6672 285 389 279 953 14% 4% TOTAL 53024 7954 0 0 39 39 0% 15907 337 1017 514 1868 12% 1907 4%

I-TECH 27706 4156 0 0 0 0 0% 8312 14 83 17 114 1% 114 0% REF_COMP (90% Referrals 6005 367 of REF_NEW) USAID 20016 3002 0 0 8 8 0% 37 266 56 359 6% 2% TOTAL 47722 7158 0 0 8 8 0% 14317 51 349 73 473 3% 481 1%

I-TECH 403 403 0 0 76 76 19% 0 78 1 0 79 20% 155 38% INDI_TRAIN 1st 90 0 99 (CATS Trained) USAID 157 157 0 0 16 16 10% 77 6 0 83 53% 63% TOTAL 560 560 0 0 92 92 16% 0 155 7 0 162 29% 254 45%

Performance Data

The data in Table 1 and notes present progress in specific services and core indicators for Game Changer.

• Q2 performed better than Q1 in all key indicators through program reach and also system set up. All CATS were trained in the period under review and hence that resulted in more reach through CATS.

• After the recruitment of all CATS in the second quarter, there was a 65% target achievement in the period under review and overall to date 30% has been achieved towards the overall targets.

• Identification of AFRI_TR_NEW has been a challenge since most of the identified CAYPLHIV are already on treatment. 15% were identified during the report and cumulatively 5% has been achieved to date. Building of linkages between CATS and Facilities was hampered because of lack of finance to do mentorship, this is anticipated to change when there is consistent flow of funds to foster those relations and improve the linkages.

• 83% CAYPLHIV on treatment were identified during the period under review and overall 39% has been reached that are currently on treatment. Linkages and referral of those not on treatment is being done once they have been prepared enough to start treatment.

• Mobilization for CAYPLHIV to get tested has been done through index case identification and Referral. To date 23% has been achieved on the overall annual target. The results have shown a high yield of 24.6% from quarter 1 and 2 combined. More support still needs to be given to all the districts so that they are well versed in index case identification. Featured Closer Look

MK’s Second Chance

“My near-death experience in Botswana and the support which I received from the CATS and my peers makes me feel like I have been given a second chance,” said MK.

MK is a 19-year-old boy living with HIV from Hingwe village in Bulilima district. His story mirrors those of several adolescents and young people living with HIV from his village and the district as a whole. It is a story of overcoming adversity through hope and resilience. As is the case with many young people in the area, MK was drawn by opportunities across the border in Botswana. The location of his village makes it easy for him to cross over using informal routes in the bush to the nearest city of Francistown in Botswana, where he and his friends went to seek employment. MK took his medicine with him on his journey to Botswana.

It took him two days to find a job in Botswana—not in the city lights of Francistown but in a farming area, 80km from town. Little did MK know that he would not have access to medical services to provide for his ART refill, as Botswana does not offer medication to foreigners who illegally enter the country.

When he ran out of his ART supply, MK could not travel back to Zimbabwe immediately for a resupply due to financial constraints—he had not yet received his salary. Unfortunately, he fell ill. Seeing the seriousness of the illness, his friend found means to bring MK back to Zimbabwe via the same illegal crossing points. He was taken to a local clinic as his condition had deteriorated.

After showing signs of recovery, MK was referred by service providers at the clinic to Africaid for further support and adherence counselling. A CATS started to visit him twice a week to check on his condition.

MK has fully recovered and has gone back to Botswana to work. Following advice from the CATS, he sought employment in a farming area closer to the border so that he can come back to Bulilima every month for medication and to attend a support group.

MK will stays in close contact with the CATS using the district WhatsApp group so that he will not miss his review dates. He now understands the importance of adherence, which was revealed by his experience in Botswana and emphasized by the CATS, who used Africaid’s Our Story game during adherence counselling sessions. DREAMS

DREAMS is a PEPFAR-funded initiative being implemented in Zimbabwe. DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) seeks to reduce the incidence of HIV in adolescent girls and young women, 15-24 years, by 40% in six districts of Zimbabwe by end of 2017. DREAMS is ensuring a combination package of HIV prevention services for adolescent girls and young women through USAID partners working in Zimbabwe in collaboration with the Government of Zimbabwe.

As a DREAMS partner and sub grantee through Management Sciences for Health (MSH Inc.), Africaid is now drawing on its technical expertise and existing technical assistance to line Ministries and the National AIDS Council to support the DREAMS project in two of the core package of HIV prevention services being implemented: HIV Testing and Counselling and School based HIV prevention.

Objectives:

1. To improve uptake of youth friendly HIV Testing services, through peer led community based mobilization for 61 915 adolescent girls and young women, 15-24 years old, in six districts of Zimbabwe by 2017.

2. To strengthen the capacity of 842 teachers to provide comprehensive sex and sexuality education for adolescent girls and boys in 211 schools in six districts by 2017

3. To strengthen the capacity 195 health workers to provide youth friendly HTS for 36 622 adolescent girls and young women, 15-24 years old in six districts of Zimbabwe by 2017 4. To build the organizational capacity of Africaid in preparation for direct USAID funding in future

Stakeholder engagement for improved coordination of DREAMS activities

All the DREAMS districts managed to conduct stakeholders meetings which are aimed at strengthening the coordination of DREAMS activities during the period under review. DREAMS Innovative Challenge partners were also introduced during the meeting and these are SAYWHAT, Nzeve, Culture Fund and YAZ. Culture Fund is working towards demystifying negative cultural practices which hinders AGYW from accessing sexual reproductive health services. The issue of referrals was discussed during the meeting and partners were encouraged to link AGYW to various services to ensure that all their needs are met. Other meetings which took place during the quarter include the Provincial NAC meeting on key populations, the provincial NAC quarterly stakeholders meeting, the District Child Protection Committee training on child protection in emergencies, DA and PA meetings with NGOs as well as RDC social services committee meeting.

16,234 community members mobilized for HTS

High volume events and other community organized community gatherings were utilized as platforms for mobilizing AGYW for HTS. Collaboration with PSI and MoHCC were also used as this facilitated for the completion of referrals. Reaching out to AGYW aged 20 – 24 remains a challenge across districts though there is a slight improvement since Africaid started partnering with testing organizations such as MoHCC and PSI. Attribution of community mobilization to HIV testing remains a challenge as it is difficult to follow up the individuals mobilized and actually took up the test. The CATS in the DREAMS district have been mentored to conduct index case finding and this has faced some challenges as the Zvandiri Mentors are finding it difficult to offer maximum support due to limited Community Mobilization in collaboration with resources during the period under review. PSI in Gweru Rural with CATS on the ground mobilizing for HTS. 182 health workers supported through mentorship

In Makoni, Africaid managed to mentor 5 health workers from two health facilities namely Vhengere and Masvosva Clinics. Issues discussed during the mentorship were focussed on disclosure, adherence, adolescent clinic and viral load tests. These two facilities have functional support groups for children, adolescents and young people with HIV (CAYHIV).

Performance Data

The data in table 2 and notes present progress in specific services and core indicators for DREAMS.

AFR_HTS_MOB| Number of individuals mobilized for HTS: In response to the success of Africaid’s index case finding pilot in Harare, index case finding is being adopted and scaled up in DREAMS districts. This will focus on children, adolescents and adults on ART as the index case who are being identified by CATS in the health facilities and home. It is anticipated that this new strategy will provide a more targeted approach to HTS mobilization of at risk AGYW. This will draw closer the attribution of HTS to the mobilization.

REF_NEW|Number of individuals referred for service(s) during the reporting period: There has been a significant improvement in the number of referrals as a result of the MoHCC standard referral process. The funding cash-flow has restricted the scale of the improvement in referral – e.g. reducing coordination meetings, mentorship, printing and follow-ups. Continuous capacity building among CATS and staff to ensure that there is regular and consistent use of these tools so that no referrals are undocumented. Ensure that tools are regularly and consistently being used and also to ensure that all service directories are being used by CATS through Mentorship.

REF_COMP|Proportion (%) of individuals referred for service(s) that completed the referral: Service availability is sometimes an issue among the rural communities. The services will be central in the and hence it sometimes affects the completion. For Gender Based Violence a transport voucher system is coming into place but there are still issues of distances travelled to services and availability off the actual services is also an issue

ACT_COMP|Proportion (%) of service providers having acted on at least 50% of the agreed action points: The greater part of mentorship has commenced in Quarter 2 after the recent training of the teachers and hence there will be an increase in those mentored. A mentorship plan has been developed that requires mentorship to be done on a monthly basis.

Table2: Summary DREAMS performance DREAMS Code Indicator Category Target Overall Results Q1-5 % Target Cumulative (Y1) Male Female (FY16 & +(Y2) 17) Total HTC_TST_TA No. individuals who received HIV testing Age: 15-19 34990 10587 31019 41606 89% and counselling (HTC) services for HIV and Age: 20-24 64933 15830 47496 63326 73% receive their test results Age: Total 99923 26417 78515 104932 79% CLUB_ATTND Number of individuals that are attending Age: 15-19 19125 8077 10308 18385 54% DREAMS supported meetings/club events Age: 10-14 0 216 397 613 Age: Total 19125 8293 10705 18998 56% AFR_HTS_MOB Number of individuals mobilised for HTS Age: 15-19 15159 2116 8936 11052 73% Age: 20-24 46756 1003 4179 5182 11% Age: Total 61915 3119 13115 16234 26% REF_NEW Number of individuals referred for Age: 15-19 12127.2 133 722 855 7% service(s) during the reporting period. Age: 20-24 37404.8 89 418 507 1% Age: Total 49532 222 1140 1362 3% REF_COMP Proportion (%) of individuals referred for Age: 15-19 90% 24% 33% 28% 31% service(s) that completed the referral. Age: 20-24 90% 18% 14% 16% 18% Age: Average 65% 21% 23% 22% 34% IND_TRAIN Number of individuals trained to deliver Category: Teachers 841 395 434 829 99% services Category HCW 195 47 135 182 93% Category: Total 963 442 569 1011 105% ACT_COMP Proportion (%) of service providers having Category: Teachers 100% 10% 21% 16% 16% acted on at least 50% of the agreed action Category HCW 100% 213% 113% 163% 163% points Category: Total 100% 112% 67% 89% 89% ACT_COMP Proportion (%) of service providers having Category: Teachers 6 41 93 134 (numerator) acted on at least 50% of the agreed action Category HCW 4 100 153 253 points Category: Total 10 141 246 387

Featured Closer Look

USAID Visit to Gweru

Gweru District was visited by USAID during the month of March 2017 and this provided an opportunity to get feedback from the funders on their views on the DREAMS programme. CATS were able to showcase how they are contributing to the DREAMS project in line with the 90-90-90 targets. Maboleni clinic was visited and the District Medical Officer for Gweru was also present during the visit. In their remarks, the DMO and the Nurse in Charge at the clinic expressed great appreciation of the role being played by CATS in mobilizing for HTS, linking and tracking AGYW for treatment as well as promoting adherence among adolescents on ART.

Under the in-school component, learners at Mudubiwa Secondary school were able to testify how they have benefited from the G & C sessions being conducted by trained G & C teachers. Topics like stigma and discrimination have gone a long way in promoting a conducive learning environment where learners living with HIV can freely interact with other learners without fear of being discriminated. Learners living with HIV are now opening up to their teachers and are being linked to CATS services.

DREAMS partners however were encouraged to document the layering of services which is taking place on the ground but not coming out clearly in the database. Documentation of success stories was also emphasized. USAID members visit health Africaid Capacity Improvements facility in Gweru and interact with CATS Improved M&E capacity of CATS

Training of CATS and staff on M & E tools was key in the reporting period. All the CATS were capacitated with basic data collection strategies, data collection tools and were also oriented on key indicators that will be tracked. The whole M & E system was also trained to the CATS and staff during Provincial review meetings and CATS coordination meetings. This had a positive impact on the program reach during the period under review since this increased understanding of how the program should be implemented. Capacity building of staff on key M & E document such as indicator reference sheets and Performance Monitoring Plans also enhanced the knowledge of most of the new staff. Moving forward tools have been translated into vernacular and will continue to be distributed and this is expected to go a long in ensuring data quality.

Zvandiri Database roll-out

The rolling out of the Zvandiri Client Tracking database gathered momentum during the period under review. Most of the districts that have internet connectivity have started using the system although more still needs to be done. The next phases of the databases involves rolling out a mobile app that will enable entry of data at community level by CATS which will be expected to commence in the third quarter. The Zvandiri database will be a tool that will be used to guide all organization reporting requirements by end of the third quarter.

Grant management and capacity development support

LMG continued to provide Africaid with support to manage their sub-agreement, including oversight on the financial, technical, and contractual obligations of the agreement.

In discussion with USAID Zimbabwe and Africaid, LMG prepared a capacity development work plan to address priority areas in M&E, finance, and communications. LMG submitted the last version of the capacity development work plan to USAID in December 2016. During this reporting period LMG continued to engage with USAID in reviewing and making adjustments to the workplan and budget striving to arrive at an agreed upon way forward. The final directive from USAID was to allocate remaining/available LMG funds to Africaid i.e. extending the period of performance to the end of May 2017 and increasing the obligation. Challenges, Solutions, and Lessons Learned

Funding: The financial component of programming directly impacts the progress of targets. Quarter two was characterized by funding challenges that resulted in limited activities in most of the districts. While Africaid’s relevant departments made efforts to ensure compliance with donor regulations, there was insufficient funding and cash for many of the planned district activities.

• The key lesson learned is the need to comply with the financial obligations of respective donors, and in the future working with the finance and administration department to achieve them.

• Another key lesson was the opportunity of utilizing mobile money for payment to service providers and for CATS allowances. District personnel were encouraged, where possible, to utilize mobile money and the Harare, Chitungwiza and Seke CATS were assisted to open bank accounts for payment of their monthly stipends.

Political Challenges: The current social and political climate in the country has a significant effect on program operations in the districts. In light of the upcoming 2018 general election, the district teams must show caution regarding where and how they conduct their activities. Africaid must maintain strong ties with the district administrators and to submit regular program updates.

• Recent meetings with the provincial administrators emphasized that in this political climate, all NGOs must be known in their districts and must work within the scope of their MOUs.

• The need to engage local leadership such as traditional leaders and chiefs is key to success at the grassroots level, as they mobilize the community to support community-based programs. This was evident in Mt Darwin, where Africaid engaged the local leadership who now share their support of the program. In the words of the Chief Matope of Mt Darwin, “this is the program we were waiting for, for a long period. How can the community grow when young people are not catered for especially in HIV/AIDS? I shall fully support the Zvandiri program through cascading down the information to my children, the general community, and all other village heads and headman who failed to attend this crucial meeting.”

Logistical Challenges: A lack of vehicles and limited mobility created challenges for the Africaid district teams to provide care and support to the CATS and mentorship to facility-based health care workers. Additionally, flooding from the heavy rains and storms this year left many CATS in situations where they could not cross the rivers or cross damaged roads to work at their assigned health facility or conduct home visits.

• District teams collaborated well with the ITECH teams and MoHCC to travel within the districts, but the gaps to certain catchment areas and CATS’ homes remained significant.

• As the financial situation improves, Africaid will purchase and distribute bicycles to all the remaining districts.

Staffing Challenges: The attrition rate of CATS in quarter two was surprisingly high. Africaid lost 62 As the financial situation improves, CATS, representing a 10 percent attrition rate. This Africaid will purchase and distribute attrition severely impacted the program, leaving bicycles to all the remaining districts. some facilities with no CATS, and some high volume Here, an Africaid Zvandiri Mentor is sites with insufficient CATS to provide services. Sadly, handing over a bicycle to an excited CATS three of the aforementioned CATS passed away from in Marondera District opportunistic infections (TB, meningitis, and cancer) during quarter two. Above : Flooding in Game Changer • Africaid will look at the reasons for attrition and implementation. work towards reengagement. A CATS spreadsheet is Below: Africaid Zvandiri Mentor is regularly updated at the district level to indicate the handing over a bicycle to an excited status of CATS, including those who have left for any CATS in Marondera District. reason and any follow up completed.

• Index testing at the district level has presented as challenging, and Africaid is providing retraining during head office mentorship visits and CATS coordination meetings.

• ITECH, PSI, and Africaid held national, provincial, and district-level meetings to enhance collaboration between ITECH and PSI roving testers and ITECH roving initiators with CATS during index case findings in order to provide a full package of care at one visit. The Way Forward

• Africaid will conduct a “mop-up” training to cater to the CATS that were originally missed in Hurungwe, Kadoma, and Lupane (as highlighted in the Q1 report), as well as other districts to compensate for the high attrition rate and need to train new CATS. In a recent realignment request, Africaid requested that increased funding be moved into CATS training. CATS are the backbone of this program, and if they lack facilities, it has an incredibly deleterious effect on the program and its results.

• Strong collaborations with MoHCC and ITECH officers working on the ground is the mainstay to reaching and supporting the most vulnerable CAYPLHIV. The Zvandiri Mentors have established good working relationships with the ITECH teams in the districts during CATS coordination meetings, mentorship, and in some cases, the sharing of offices. To improve Afri_Tr_New numbers, proposals at the national and provincial level suggested that CATS collaborate with the ITECH and PSI roving testers and roving initiators during index case findings. This discussion will continue when specific dates for visits are chosen. To enhance utilization of the MoHCC referral tool, ITECH and Africaid propose sensitization trainings for health care workers in quarter three.

• Africaid will increase inclusion of political officials and key stakeholders during any visits from the head office, district quarterly planning, and mentorship visits. Enhanced collaborative efforts will ensure that Africaid program activities remain transparent and all necessary parties are aware and supportive of the program’s plans.

• New ways of meeting program targets will be explored, including the program’s presence in different entry points of health facilities and, with the support of the health facility staff, the strengthening of relationships between CATS and health care workers. Increased trust and accountability will enhance the necessary bidirectional referrals between facilities and CATS as well as between Africaid and other partners.

• Offering continual support to the CATS is essential. Africaid will support CATS during the coordination meetings. Zvandiri Mentors and Interns will be encouraged to create time for individual sessions with each CATS to offer them continual support as program beneficiaries. Africaid will introduce standard operating procedures (SOPs) for supervision and caring for the CATS at the national level and will be rolled out at the district level in quarter three. Provision of care and support for the CATS is integral to their health and well-being as well as the success of the program. These SOPs and guidelines will be utilized in all districts. Africaid is collaborating with ITECH and MoHCC to ensure that all CATS in Harare, Chitungwiza, Seke, and the districts will have access to viral load testing.