Clinical & Community HIV & AIDS Services Strengthening (CHASS)
Quarter 1, FY17 Progress Report
LIFE OF PROJECT SUMMARY
Implementing Partner: Family Health International (FHI 360)
Activity Name: Clinical and Community HIV/AIDS Services Strengthening Project (CHASS)
Activity Goal: CHASS’s goal is to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in four provinces.
Activity Objectives: To contribute toward HIV/AIDS epidemic control in Mozambique, CHASS seeks to:
1) Increase coverage of antiretroviral treatment (ART) to 90 percent. 2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively. 3) Increase the average CD4 count at initiation of ART from 350 to 500 cells per cubic millimeter. 4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB. 5) Operationalize viral load testing. Life of Activity (start and end dates): August 2010 – July 2018
Total Estimated Contract/Agreement Amount: US$137,982,152[1]
Total Amount Obligated (to date): US$81,799,660.00
Current Pipeline Amount: US$12,474,245
Actual Expenditure through This Quarter: US$69,325,415
Estimated Expenditures Next Quarter: US$12,474,245
Geographic Focus: Niassa, Tete, Manica, and Sofala Provinces, Mozambique
Report Submitted by: Dr. Joaquim Fernando
Submission Date: February 3, 2017
[1] After de-obligation of funding for voluntary medical male circumcision. 2 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Contents LIST OF FIGURES ...... 4 LIST OF TABLES ...... 5 EXECUTIVE SUMMARY ...... 8 PROJECT OVERVIEW ...... 12 PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA ...... 14 IR1: Strengthen facility-based HIV services ...... 14 HIV Testing and Counseling ...... 14 Care and Treatment ...... 18 Pediatric Antiretroviral Therapy ...... 26 Laboratory Services ...... 30 Pharmaceutical Care Systems and Services ...... 32 Prevention of Mother-to-Child Transmission ...... 36 TB/HIV Integration ...... 39 Nutrition Support...... 42 Health System Strengthening ...... 43 Quality Improvement ...... 46 IR 2: Strengthen community-based HIV services – access, quality, and retention ...... 48 IR 3: Strengthened referral/linkage systems between community and facility-based services 51 Strategic Information ...... 54 Electronic patient tracking system ...... 54 Community data systems ...... 56 Data use ...... 56 PROJECT MANAGEMENT AND IMPLEMENTATION ...... 57 MAJOR PRIORITIES/ACTIVITIES PLANNED FOR NEXT QUARTER ...... 61 ANNEXES ...... 63 Annex 1. Sites in need of particular attention ...... 63 Annex 2. Facilities that benefited from CHASS commodity management technical support .... 67 Annex 3. Table illustrating the number of facilities receiving the support as listed above ...... 68 Annex 4. HFs supported in management of FILAs and LRDA in the four provinces ...... 68 Annex 5. CHASS in-service training achievements over the quarter, FY17 Q1 ...... 69
3 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
LIST OF FIGURES Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q1 ...... 9
Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q1 ...... 9
Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and ART support for facilities ...... 13
Figure 4. Performance against target in HTC, by sector, FY17 Q1 ...... 15
Figure 5. HIV positivity yield by sector and quarter, life of project ...... 16
Figure 6. Number tested over time through C-HTC, by province and quarter, life of project ...... 17
Figure 7. ART cascade for FY17 Q1 ...... 19
Figure 8. Number of patients newly enrolled in ART by quarter and province, FY17 ...... 20
Figure 9. Number of new patients enrolled in ART compared with target, by province, FY17 Q1 ...... 22
Figure 10. Progress toward the annual target for patients newly enrolled in ART, by province and quarter, life of project ...... 22
Figure 11. Number and percent of new HIV-positive patients eligible/newly initiated on ART in Q1 of FY17* ...... 24
Figure 12. Number of infants born to HIV-positive women who received an HIV test within 12 months of birth, FY17 Q1 ...... 27
Figure 13. Number of children with advanced HIV infection newly enrolled on ART, by project over the life of the project ...... 28
Figure 14. ADR notifications rates by province, FY17 Q1 ...... 35
Figure 15. PMTCT cascade, FY17 Q1 ...... 37
Figure 16. Option B+ coverage among HIV-positive pregnant women, by province and quarter ...... 38
Figure 17. TB cascade, FY17 Q1 ...... 40
Figure 18. TB patients registered, by province and quarter ...... 41
Figure 19. Map of EPTS sites by year of hand over ...... 55
Figure 20. Site accessibility by support type, FY17 Q1 ...... 60
4 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
LIST OF TABLES Table 1. Performance on selected indicators at the end of FY17 Q1 ...... 10
Table 2. Comparison of HTC DSD and TA targets from FY16 and FY17, by sector ...... 15
Table 3. Health facilities with highest levels of growth in new enrollees between FY16 Q4 and FY17 Q1 21
Table 4. GAAC enrollment by province, FY17 Q1...... 26
Table 5. Number of patients enrolled in three-month dispensing in the HFs ...... 33
Table 6. Performance of key PMTCT indicators by province, FY17 Q1 ...... 37
Table 7. Results from a PDSA cycle on engaging circulating case managers to improve ART initiation .... 51
Table 8. Referrals reported for HF services—referrals made and patients received, FY17 Q1 ...... 52
Table 9. Funds disbursed to DPSs ...... 58
Table 10. Funds disbursed to SDSMASs during Q1 FY 17 ...... 59
Table 11. Funds disbursed to CBOs ...... 59
Table 12. Coverage of sites for data collection by province and support type, FY17 Q1 ...... 61
5 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
LIST OF ACRONYMS AND ABBREVIATIONS
ADR Adverse Drug Reaction AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral CHAI Clinton Health Access Initiative CBO Community-Based Organization CCR Consulta da Criança em Risco (High-Risk Consultation for Children) CDC U.S. Centers for Disease Control and Prevention CD4 Cluster of Differentiation 4 CHASS Clinical and Community HIV/AIDS Services Strengthening C-HTC Community HIV Testing and Counseling CS Centro de Saúde (Health Centre) DDM Direcção Distrital de Medicamentos (District Drug Directorate) DPM Direcção Provincial de Medicamentos (Provincial Drug Directorate) DPS Direcção Provincial da Saúde (Provincial Health Directorate) DSD Direct Service Delivery EID Early Infant Diagnosis EPTS Electronic Patient Tracking System FY Fiscal Year GAAC Grupo de Apoio e Adesão da Comunidade (Community Support and Adherence Group) HF Health Facility HIV Human Immunodeficiency Virus HRH Human Resources for Health HSS Health Systems Strengthening HTC HIV Testing and Counseling IEC Information, Education, and Communication IR Intermediate Result M&E Monitoring and Evaluation MCH Maternal and Child Health MISAU Ministerio da Saúde (Ministry of Health) OGAC Office of the U.S. Global AIDS Coordinator OVC Orphans and Vulnerable Children PCR Polymerase Chain Reaction PDSA Plan-Do-Study-Act PEPFAR U.S. President’s Emergency Plan for AIDS Relief PICT Provider-Initiated Counseling and Testing PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PPP Public-Private Partnership PS Posto de Saude (Health Post) RTK Rapid Test Kit PV Pharmacovigilance SCBA System Capacity Builder Approach
6 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
SDSMAS Serviços Distritais de Saude, Mulheres Acão Social (District Directorate for Health, Women, and Social Action Services) SMS Short Message Service TA Technical Assistance TB Tuberculosis TSV Technical Support Visit UATS Unidades de Aconselhamento e Testagem em Saúde (Stand-Alone Voluntary Counseling and Testing) UCSF University of California at San Francisco VCT Voluntary Counseling and Testing WHO World Health Organization
7 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
EXECUTIVE SUMMARY In this report, the Clinical and Community HIV/AIDS Services Strengthening (CHASS) project presents achievements for the first quarter of fiscal year (FY) 17. Despite the Christmas season, a period when there is often a decline in service utilization, the overall performance was high. Although CHASS did not achieve the new ambitious quarterly targets in all provinces or for all services, high levels of performance, especially in Manica province where performance improved most this quarter, suggest that the project will be able to achieve its targets over the course of the year.
In the first quarter of FY 17, CHASS surpassed its targets in terms of the number of individuals who received HIV testing and counseling (HTC) and received their test results by 24 percent. CHASS continued shifting the focus of HTC from enabling people to know their HIV status to HIV case identification, enrolment in care, and initiation on antiretroviral therapy (ART). This paradigm shift, especially in community HTC, is already showing dividends as exemplified by this quarter’s positivity rate being roughly double that seen in FY16. This quarter, CHASS-supported sites tested 351,873 people for HIV.
Out of 351,873 people tested for HIV, 22,926 people tested positive for HIV and 15,575 (68 percent) of them were enrolled in care across the four provinces (Figure 1). The number of patients newly enrolled in ART was higher (17,959) than the number enrolled in care because of the implementation of Test and Start at select sites where all patients currently on pre-ART were eligible to start ART. The number of patients newly enrolled in ART increase by 7 percent relative to last quarter and was the largest number reported in any quarter to date. Manica and Niassa saw dramatic increases in the number of patients newly enrolled on ART (by 21 percent in Manica and 24 percent in Niassa). This was the result of extraordinary efforts including the allocation of additional staff at the triage units to improve PICT of children and daily monitoring of HIV-positive cases and linkage to ART initiation. However, performance in both Manica and Sofala was still below the expected level. Overall, the percent of newly diagnosed HIV-positive clients newly enrolled into ART increased from just above 70 percent in the past two quarters to almost 80 percent this quarter. This further closed the gap in patients who were enrolled in care and who also initiated ART, in part due to the further implementation of Test and Start in key sites.
8 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q1
CHASS-supported sites also showed good performance in terms of the percentage of HIV-positive pregnant women who received antiretroviral (ARV) drugs to reduce the risk of mother-to-child- transmission, with 98 percent of women receiving ARV drugs. The quarterly cascade for the prevention of mother-to-child transmission (PMTCT; Figure 2) shows the continued challenge in ensuring coverage of all women registering for antenatal care (ANC) with HIV testing, although this may be an issue with the new reporting forms rather than low coverage. At the same time, a slightly larger proportion of HIV- positive women were on ART than last quarter (97 percent versus 95 percent).The cascade also highlights the need to continue to reinforce the importance of testing all exposed infants, although the percentage shown is an imperfect comparison (women who register for ANC this quarter will likely deliver three to four months later, and their babies will not be eligible for complete testing for another year).
Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q1
9 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
More details of CHASS’s performance toward targets are in Table 1, which summarizes performance for key indicators in the first quarter of FY17 for all CHASS provinces. Achievements in red are those for which CHASS achieved less than 85 percent of the quarterly target, and those in green reflect achievement at or above 85 percent of the quarterly target.
Table 1. Performance on selected indicators at the end of FY17 Q1 FY17 % Indicator Annual Target Q1 achievement # of individuals who received Counseling and Testing (C&T) services for HIV and received their test results--all sectors 1,128,442 351,873 31% Manica 712,537 135,897 19% Niassa 43,270 46,021 106% Sofala 219,808 86,707 39% Tete 152,827 83,248 54% # adults and children w/advanced HIV infection newly enrolled on ART 79,277 17,959 23% Manica 35,392 6,325 18% Niassa 3,389 1,981 58% Sofala 29,697 6,216 21% Tete 10,799 3,437 32% % of pregnant women with known HIV status 99% 98% 99% Manica 99% 99% 100% Niassa 99% 101% 102% Sofala 99% 96% 97% Tete 99% 95% 96% % of HIV-positive pregnant women who received antiretrovirals to reduce risk of mother-to-child- transmission 99% 97% 98% Manica 99% 97% 98% Niassa 99% 94% 95% Sofala 99% 98% 99% Tete 99% 97% 98%
In response to consistent underperformance of Manica province, especially regarding initiating new people living with HIV (PLHIV) on ART and retention, CHASS constituted and deployed in the province a task force composed of senior technical officers from the country office and Manica province teams. The task force spent most of December 2016 identifying causes for poor retention and poor initiation of new PLHIV on ART, and offering solutions. The team focused on the ten highest volume health facilities (HFs). Major findings include: o Over estimation of defaulters because some PLHIV who pick up ART refills are recorded as defaulters. This is due to inadequate triangulation of data across sectors within health facilities as well as to limited coordination between service units, HFs, and community- based organizations. o Delayed completion of registers. o Some service delivery points are not optimizing provider initiated testing and counseling (PITC), leading to missed opportunities for identifying PLHIV for initiation on ART
Major actions recommended/taken were more aggressive PICT and case management of persons who test HIV-positive, improved documentation in all service delivery units, coordination between different 10 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
service delivery points (eg ANC, pharmacy and CCR) and strengthened multipoint HTC. By the end of December 2016, HIV testing using PICT in the 10 HFs had increased from 29 percent to 49 percent, while average daily ART initiation had gone up from 48 to 76 PLHIV. Regarding retention data, triangulation of information had reduced perceived treatment defaults by 30 percent. The effectiveness of this activity will be fully assessed using Q2 results.
CHASS continued supporting the Ministerio da Saude (Ministry of Health) (MISAU) in rolling out Test and Start in all phase 1 sites in the four provinces, as well as implementing the differentiated care model in which stable patients 1) receive three-month ARV drug refills and 2) return for consultations every six months. CHASS zonal teams mentored HF workers in participating sites in both initiatives to ensure awareness of, implementation of, and compliance with the respective national guidelines.
CHASS continued to expand the electronic patient tracking system (EPTS) this quarter, with six new sites with retrospective data entry completed. Out of these, five sites were handed over to the direcção provincial da saúde (provincial health directorate) (DPS) this quarter: one in Niassa, two in Manica, and two in Tete. In Sofala, CHASS began implementation in CS Ponta Gea, one of the biggest and most challenging sites, it is anticipated that the site will be complete by the end of Q2. This progress has made it possible for CHASS to report from 30 EPTS sites this quarter, up from 24 at the end of FY16.
Although the Mozambique National Resistance (RENAMO) and the Government of Mozambique agreed on a ceasefire on December 29th, this was after the end of the quarter. The ceasefire has substantially improved the security situation and allowed for manual data collection at some sites. However, during the quarter, the situation continued to affect our ability to provide TA in affected districts including in Manica: Machaze, Mossourize, Guro, Tambara, Macossa, and Barue. In Sofala it included Caia, Marromeu, Gorongoza, Maringue, Chibabava, Machanga, Muanza, Chemba, and Cheringoma.
11 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
PROJECT OVERVIEW
The Clinical and Community HIV/AIDS Services Strengthening (CHASS) project aims to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in the four provinces of Sofala, Manica, Tete, and Niassa by ensuring that the right HIV/AIDS interventions are implemented, at the right time and in the right places, so as to contribute to the desired goal of epidemic control in Mozambique. This eight-year, US$137,982,151 USAID-funded project began on August 1, 2010, and will end on July 31, 2018.
CHASS is pursuing five objectives:
1) Increase coverage of antiretroviral therapy (ART) to 90 percent. 2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively. 3) Increase the average CD4 count at initiation of ART from 350 to 500 cells per cubic millimeter. 4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB. 5) Operationalize viral load testing.
To achieve the above objectives, CHASS combines technical capacity strengthening of health facilities (HFs) and community-based organizations (CBOs), direct support for quality and integrated HIV/AIDS service delivery, and health systems strengthening (HSS) at provincial, district, and HF levels. The project is implemented jointly with local organizations, district health teams, provincial health teams, and the Ministerio da Saúde (Ministry of Health) (MISAU). In support of the USAID Forward principles, CHASS puts more emphasis on technical assistance (TA) to host government and local organizations to enhance local ownership of the national response.
In line with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 3.0, CHASS uses a data-driven approach that strategically targets geographic areas and populations to achieve the most impact for investments. This approach also aims to close existing coverage gaps and increase access by saturating services in districts and communities where HIV prevalence and unmet need are high. CHASS continuously strives to go where the virus is and support implementation of evidence-based interventions for populations at greatest risk in areas of greatest HIV incidence. CHASS is driven by the global PEPFAR impact agenda, with a focus on doing the right things in the right places at the right time. The project seeks to 1) improve site monitoring, strengthen program quality, and scale up core interventions; 2) focus on districts and communities with the highest disease burden so as to maximize resources; and 3) utilize the three years of the project to scale up interventions necessary to reduce new infections and reduce the costs of the epidemic in the long term. CHASS provides differentiated packages of support (i.e., scale-up, sustenance, transition/central support) to HFs and prioritizes scale- up in districts and HFs that have the highest HIV burden with the goal of reaching saturation levels (Figure 3). In total, CHASS supports 309 ART sites, 370 prevention of mother-to-child transmission (PMTCT) sites, and 373 HIV testing and counselling (HTC) sites in 56 districts.1
1 These sites do not include PMTCT sites, all of which do HTC within PMTCT. They include sites that provide either voluntary counseling and testing or provider-initiated testing and counseling. 12 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
CHASS has three intermediate results (IRs):
IR1: Strengthened facility-based HIV services. IR2: Strengthened community-based HIV services. IR3: Strengthened referral and linkage systems between community and facility-based HIV services.
Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and ART support for facilities
The next sections of the report highlight accomplishments by IR, in specific program/technical areas from October to December 2016. The sections state how, in the past quarter, CHASS worked with direcção provincial da Saúde (provincial health directorates) (DPSs) and with serviços distritais de saude, mulheres acão social (district directorates for health, women, and social action services) (SDSMASs) to address obstacles affecting access to and quality of facility-based HIV/AIDS services in the four provinces. 13 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA
IR1: Strengthen facility-based HIV services
The ultimate goal of CHASS activities is to enable HFs to scale up the provision of integrated health and HIV/AIDS services and meet the standards specified by MISAU and other world bodies such as the World Health Organization (WHO). To achieve this, the project supports interventions in a wide range of areas including improving the knowledge and skills of health workers, enhancing the capacities of provincial and district health personnel to effectively supervise and manage HFs, activating more sites for HIV/AIDS services so as to enhance access, improving documentation and reporting at the HF level, and improving supply chain and logistics management to enhance the security of health commodities. Strengthening facility-based services also entails improving linkages and referrals both within the HFs and between HFs and CBOs or other service providers so as to ensure a continuum of care for PLHIV.
HIV Testing and Counseling
The goal of CHASS HTC activities is to ensure that 90 percent of people with HIV in all four provinces are diagnosed. This is being pursued by emphasizing HTC for populations and locations that are likely to yield high rates of HIV positivity. The project continues to support multiple approaches including routine opt-out testing, provider-initiated counseling and testing (PICT), unidades de aconselhamento e testagem em saúde (stand-alone voluntary counseling and testing) (UATS), and community HIV testing and counseling (C-HTC) that emphasizes index case testing. In fiscal year (FY) 17, the target is to offer HIV testing and counselling to 1,517,184 individuals in locations and from groups likely to have high HIV positivity rates to receive HTC services and know their results. This is 175 percent of the 867,974 targeted in FY16. To achieve the ambitious FY17 HTC, CHASS put more emphasis on:
● Prioritizing interventions in population groups likely to yield high HIV positivity rates, and focusing on the “right” geographic areas (high prevalence districts, hot spots for key populations, PICT in multiple points of service in HFs, and TB DOT sites). ● Organizing patients flow and improving documentation (HTC registers) in all HTC sites so as to reduce missed opportunities and enhance data capture. ● Deploying more counselors in high-volume HFs to improve pre- and post-test counseling as well as adherence counseling and support.
Overall, this quarter, CHASS tested 351,873 people for HIV, or 96 percent of the quarterly target. Out of these, 22,926 (7 percent) were identified as HIV-positive. CHASS was on or above target for HTC in all sectors except TB (Figure 4). The changes in targets between FY16 and FY17 (Table 2) suggest that current targets better reflect the reality on the ground since performance is in better alignment with the targets. The TB sector, where performance was substantially below target, had more than a doubling in the quarterly target and given that most patients who register in TB services are already tested, it is unlikely that these targets will be achieved.
14 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 4. Performance against target in HTC, by sector, FY17 Q1
Abbreviations: ANC, antenatal care; CCR, consulta da criança em risco (high-risk consultation for children); VCT, voluntary counseling and testing.
Table 2. Comparison of HTC DSD and TA targets from FY16 and FY17, by sector Targets FY16 FY17 % Change
VCT 25,448 55,791 219% PICT 71,448 178,837 250% C-ATS 16,950 16,877 100% ANC (new and repeat) 66,852 82,741 124% Maternity 15,237 19,406 127% CCR (<12 months) 4,674 6,525 140% TB 5,180 6,705 129% Total 205,789 366,882 178%
The percent-positive rates varied widely by sector (Figure 5), from a high of 14 percent among those newly tested in communities to a low of less than 1 percent in maternity. In general, these positivity rates are consistent with past performance. The one exception is C-HTC, where the positivity in Q1 of FY17 was roughly double the rate seen in FY16. As discussed below, this reflects the shift to index case testing. It is also noted that the positivity rate in the TB sector seems to be declining. The percent- positive rates in the PMTCT and TB sectors are discussed in detail in the relevant sections of the report.
In terms of PICT, 375 sites reported testing at least one patient this quarter, and 59 of these sites had a percent-positive rate between 15 and 45 percent. A subset of sites (13) have had positivity rates above 15 percent for at least four of the last five quarters (Annex 1a). Because of normal fluctuations, some sites that had consistently high positivity in FY16 are no longer included because they now have had two out of the three past quarters in which positivity was below 15 percent. In one case, the positivity in Q1 fell just below the cutoff of 15 percent, and in three others the number of patients is small, which leads to unstable percentages; however, in four sites the reason for the decline is not clear and should be pursued. One site (Lissiete) has substantially expanded the number of patients tested in the past two quarters, which could have led to the decline; however, it raises a question about whether the increase 15 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
in tests is useful given that the number diagnosed was the same this quarter as when half as many people were tested. In general, given the high positivity yield of the sites identified, these sites will continue to be prioritized for PICT support.
At the other end of the spectrum, 183 sites (49 percent) had percent-positive rates below 5 percent. The proportion of sites with low positivity rates this quarter is somewhat higher than in the past. CHASS will continue to explore the reasons for low positivity in these sites. CHASS laboratory staff have been visiting districts to review testing quality in general, but have not yet focused on these sites to address all challenges related to systems, health worker attitudes, and client shortcomings.
Figure 5. HIV positivity yield by sector and quarter, life of project
With regard to UATS, positivity rates varied slightly from last quarter at the provincial level; however, again there was limited variability across the provinces (20 percent in Niassa to 14 percent in Sofala). Of the 91 sites that tested at least one person in UATS, 17 (19 percent) reported percent-positive rates greater than 20 percent, whereas 18 (20 percent) reported percent-positive rates less than 5 percent. This is quite similar to last quarter. Overall, 49 percent of the people tested were female, and 9 percent were under 15 years of age; although the percent who are female continued to remain constant over time, the percent under 15 years of age furthered the decrease seen in FY16 when it dropped from 13 percent in Q1 and Q2 to 11 percent in Q3.
Again this quarter, 20 sites had percent-positive rates below 5 percent (Annex 1A). Although some of these sites have consistently yielded low positivity rates, two of the 20 were new ATS sites and six were sites that had previously had high positivity in three quarters. On the other hand, a subset of 17 sites has had consistently high positivity rates (Annex 1b), with more than 15 percent of people testing positive in four or more quarters. These are sites that will remain focus sites for UATS. Nine sites had positivity of 30 percent or more this quarter and five of them had 30 or fewer people tested so their rates are heavily affected by a few positive patients. The remaining sites, all have high concentrations of high risk populations. For example, Chirodzi-Ponte CS III in Tete is near two mines and also provides services to
16 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
many long distance truck drivers who are at high risk for HIV. Igreja Baptista in Sofala is also on a transport corredor and serves many truck drivers and factory workers whereas Marrocanhe serves a large population of fishermen who are also a high risk group. Finally, Manga Loforte, also in Sofala, is a key population-friendly site supported by the Linkages project which is encouraging truck driver and sex workers to seek services there.
Overall, the number of people tested in UATS rebounded after a drop last quarter. Large changes were seen at the provincial level in Manica (31 percent increase) and Niassa (52 percent increase), whereas Sofala saw a 19 percent decline and Tete an 18 percent increase. The decline in Sofala is a result of two factors: 1) correcting an error by a counselor who in the past combined HF and C-HTC at Munhava HC; and 2) In Marromeu, the nurse who supported HTC was this quarter assigned duties in another section, which resulted in no HTC in UATS at the site.
Community Testing and Counseling
As shown in Figure 6, performance in C-HTC continued to decline this quarter as expected, with the transition to index case testing. Declines were seen in all provinces.
Figure 6. Number tested over time through C-HTC, by province and quarter, life of project
Concomitant to this change, the positivity rate in C-HTC increased substantially this quarter and, in fact, the yield was higher in C-HTC than in any sector other than TB. This quarter, the percent positive ranged from 9 percent in Tete to 20 percent in Sofala. There was a marked improvement by province as well (e.g., Sofala increased from 10 percent to 20 percent). Among the 29 districts conducting C-HTC this quarter2, 17 reported that more than 10 percent of people tested were positive — an increase of four from last quarter. Notably, 14 of the 29 districts reported positivity rates above the overall rate of 14 percent. The number of districts reporting positivity rates of less than 4 percent continued to decrease this quarter, with two fewer districts in this category compared with last quarter. As expected, based on past results, all of these were in Tete.
Despite a number of data challenges (outlined below) that do not allow us to cleanly disaggregate index case testing from other community testing, the results show the promise of index case testing for identifying more HIV-positive people. First, the positivity rates for index case testing were substantially
2 Five districts in Sofala (Caia, Chamba, Cheringoma, Machanga, and Maringue) did not report C-HTC this quarter but did in Q4 of FY16. This is because of insecurity that prevailed before the current ceasefire. 17 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
higher than the positivity rates for other testing in Niassa and Sofala, where the data are the best quality; second, the number of people identified as HIV-positive increased relative to Q4 of FY16 despite a reduction in tests. The positivity rate for index case testing was 18 percent in Niassa (compared with a rate of 10 percent for other C-HTC) and was 24 percent in Sofala (compared with a rate of 16 percent for other C-HTC). Overall, despite testing 11,000 fewer people in communities, almost 500 additional HIV- positive individuals were identified through C-HTC.
Challenges
● Testing of children is low—implementation of the See, Ask and Test (SAT) strategy is yet to be rollout out in all scale up HFs. This will be a major focus in Q2. ● Inadequate space for counseling and psychosocial support. CHASS is embarking on renovations to ameliorate this challenge in big HFs. ● Index case HTC data are not yet being captured properly as HF workers continue getting used to the tools. This affects follow-up of potential index cases.
Care and Treatment
The focus of CHASS care and treatment interventions is on closing the above gaps and ensuring that at least 90 percent of all people diagnosed with HIV are enrolled in care, 90 percent of those eligible are initiated on ART, 80 percent of them are retained in care at 12 months, and 90 percent of PLHIV on ART achieve viral load suppression. To achieve this, CHASS is using three major strategies: 1) strengthening capacity of ART sites to provide comprehensive and quality ART services (including adherence counseling, psychosocial support, and patient literacy to enhance enrollment in care, initiation on ART, and retention); 2) improving linkages between HTC (e.g., with “escorted referral” from HTC to ART service points), care, and treatment to reduce leakages and minimize missed opportunities; and 3) improving patient monitoring and follow-up.
After the launching of Test and Start (T & S), CHASS continued to work with DPS and SDSMAS to improve gaps identified during the assessment. Besides the priority 16 sites, CHASS paid attention to all other listed HFs offering T & S in supported provinces. Additional training on the T&S package was carried out to reach providers and HFs not reached initially. In Sofala, two classes for the HF staff of Beira Central Hospital and new healthcare workers recently seconded to HFs by CHASS in the “Test and Start’’ facilities were trained in Beira (15 HFs). In Niassa, CHASS completed the training of HF staff of Lichinga City (Provincial Hospital and 4 other HFs that were not yet implementing the T & S strategy (Lulimile, Meponda, Namacula and Chiulugo) but are currently implementing the strategy.
To increase enrolment, CHASS teams supported HFs to clean pre ART files to find all eligible cases for ART initiation (in sites where T&S is not yet being implemented). Information on CD4, viral load and any relevant information for ART initiation was inserted in each patient folder. During TA visits, CHASS teams ensured that conditions were met for T&S implementation. Search of defaulters - by phone or by activists and distribution of agendas for better handling of consultations were given particular attention. CHASS assisted DPS and SDSMAS to reproduce and distribute registers, forms and MoH guidelines for T & S In all four Provinces, the secondment of 133 additional personnel (staff) in HFs (Tete: 40, Sofala: 37; Manica: 46) contributed to the improvement of the linkage between the diagnosis sites and the care and treatment units. To improve adherence, patients received psychosocial support on the day of HIV 18 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
diagnosis, and were motivated to start the ART within 15 days. Consultation was offered the very same day of HIV diagnosis.
CHASS teams also continued ongoing TA to ART sites, prioritizing high-volume sites in scale-up districts and focusing on enrollment of HIV-positive patients in care and treatment, strengthening counseling for adherence, and supporting improved data management. During the quarter, CHASS clinical teams received capacity building support from Dr Kwasi Torpey from FHI 360 HQ and the Southern African HIV Clinicians Society with the purpose of updating clinicians involved in technical assistance. Topics covered included HIV care and treatment, pediatric ART, TB/HIV, drug-resistant TB, screening for and treatment of sexually transmitted infections, and monitoring treatment using viral load results.
Overall, performance across the ART cascade was strong this quarter. Out of 22,926 people who tested positive for HIV, 15,575 (68 percent) enrolled in care across the four provinces (Figure 7). The number of patients who started ART was higher (17,959) than the number enrolled in care because of the implementation of Test and Start at select sites where all patients currently on pre-ART were eligible to start ART. The number of patients newly enrolled in ART increase by 7 percent relative to last quarter and was the largest number reported in any quarter to date. These data are discussed in more detail below.
Figure 7. ART cascade for FY17 Q1
PLHIV enrollment in care and treatment In Q1 2017, the percent of newly diagnosed HIV-positive clients newly enrolled into ART increased from just above 70 percent in the past two quarters to almost 80 percent this quarter. This further closed the gap in patients who were enrolled in care and who also initiated ART, in part due to the further implementation of Test and Start in key sites. Overall, 17,959 patients were newly enrolled on ART across the four provinces — a 7 percent increase from last quarter and the largest number reported in any quarter to date. Manica and Niassa saw dramatic increases in the number of patients newly enrolled on ART (by 21 percent in Manica and 24 percent in Niassa) as the result of key activities including the allocation of additional staff at the triage units to improve PICT of children and daily monitoring of HIV- 19 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
positive cases and linkage to ART initiation. Tete also registered an increase, although it was just 2 percent (Figure 8). Sofala, on the other hand, saw a decrease of 6 percent from last quarter, due in large part to the four facilities that are no longer supported by CHASS (Hospital Militar, Chingussura, Estaquinha, and Mangunda). Those four facilities accounted for 10 percent of all pediatric enrollments in Sofala in Q4.
Figure 8. Number of patients newly enrolled in ART by quarter and province, FY17
At the site level, although 34 new ART sites were reported this quarter, they contributed only 644 patients (just over 3 percent of all new patients). Overall, 154 sites had an increase in the number of patients, 143 had a reduction in the number of new patients, and 11 reported the same number of new enrollees as last quarter. Eleven sites were responsible for 49 percent of the reduction in patients (Annex 1f), and one of these is a site that CHASS no longer supports. Again this quarter, CHASS gave special attention to the sites that are located in priority districts: Catandica HR and Mavissisanga CS III in Manica, Buzi Sede HR and Marromeu HR in Sofala, and Dôa CS III in Tete. Cantandica is the only site that was also on this list in Q4, and this site is located in a district that was heavily affected by the political conflict in Q1.
Sixteen sites (Table 3) were responsible for 49 percent of all the growth in patients at the site level (i.e., among those sites that saw increases in new enrollees). Of the 16 facilities that contributed to the increase in new enrollment, eight are among the 16 CHASS priority sites (highlighted in orange in the table). Another site, Gondola Sede in Manica, also received focused support this quarter because it is also a high-volume site, even though it is not among the “super 16.” Seven of the sites have seen a steady increase in the number of new patients enrolled in ART as indicated by the color coding below (red denotes the smallest number of new enrollees at the site in the past year and green the highest).
20 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Table 3. Health facilities with highest levels of growth in new enrollees between FY16 Q4 and FY17 Q1 Health Facillity Q2 Q3 Q4 Q1 Manica / Cidade De Chimoio / 1º Maio CS II 233 271 298 508 Manica / Cidade De Chimoio / 7 de Abril 234 240 269 442 Manica / Cidade De Chimoio / Chissui CSURB 83 77 145 237 Manica / Cidade De Chimoio / Eduardo Mondlane CSURB 326 297 471 676 Manica / Cidade De Chimoio / Nhamaonha CS II 281 310 351 573 Manica / Gondola / Gondola Sede CS I 172 200 212 264 Manica / Mossurize / Centro de Saude de Gunhe 14 49 20 72 Manica / Mossurize / Chiurairue CS III 28 41 15 75 Manica / Sussundenga / Dombe CS II 107 105 71 119 Niassa / Cuamba / Cuamba CSURB 144 245 156 248 Sofala / Cidade Da Beira / Macurungo PSA 191 305 232 343 Sofala / Cidade Da Beira / Manga Mascarenha CS III 102 163 175 235 Sofala / Cidade Da Beira / Manga Nhaconjo PS 282 332 449 528 Sofala / Nhamatanda / Nhamatanda Sede HR 202 160 205 257 Tete / Cidade De Tete / Cs Nº 1 - Bairro Magaia CSURB 159 170 227 287 Tete / Moatize / Moatize CS I 226 405 217 287 Tete / Mutarara / Ancuaze PS 28 3 72
Among the 16 high-priority Test and Start sites supported by CHASS, nine saw an increase of 10 percent or more in the number of new patients enrolled on ART between Q4 and Q1. One site, Munhava in Beira City, saw no change, although the number of new enrollees in Q4 was greater than in any of the earlier quarters. Strategies used to improve new enrollments included using Pre-ART data to generate lists of eligible patients who had not yet enrolled in ART and actively searching for them through busca consentida, escorting PLHIV who test positive to ART services using and continuing to promote the revised eligibility criteria (CD4 <500 for all patients regardless of age and Test and Start where allowed). In addition, as discussed above, the implementation of T&S at these sites contributed to improvements in the number enrolled.
Of the PLHIV newly initiated on ART, 16,609 (92 percent) were adults and 1,350 (8 percent) were children, and 6,017 (34 percent) were male and 11,942 (66 percent) were female. The children under 15 were equally divided by sex, as in the previous quarter; this quarter, 53 percent of youth were female, with an equal distribution of girls and boys under 5 years of age (51 percent girls). The percent of adults who were female was almost the same this quarter as last (67 percent). As noted before, the predominance of women in this older age group is in part because the prevalence of HIV is higher among women, but also because women are more likely to be tested and because of universal treatment in PMTCT. This quarter, 3,911 pregnant women were reported to be newly initiating ART. This was 35 percent of all women over 15 years of age who initiated ART this quarter — a growth of 9 percent from last quarter.
Enrollment of children on ART remains a particular challenge. The percent of children starting ART remained the same as last quarter, at 8 percent of all patients initiating ART (8 percent in Niassa and Sofala, 6 percent in Tete, and 7 percent in Manica). While Manica had a 27 percent increase in children enrolled in ART and Niassa had a 19 percent increase, Sofala and Tete both saw small decreases in the percent of patients initiating ART who were children this quarter. This quarter, the number of sites reporting that more than 10 percent of new patients were children under 15 increased, but the proportion decreased to 26 percent (89/336); only 227 sites enrolled any children. 21 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
CHASS achieved 80 percent of the quarterly target for new enrollees in ART (Figure 9) when all three types of sites — direct service delivery (DSD), TA, and transition — are included. Although this is a decrease in performance against target because of the increased targets, performance was strong this quarter. Niassa achieved 37 percent of the annual target (we would expect to achieve 25 percent of the target to be on track to achieve the annual target) and Tete is on target, having achieved 24 percent of the target. Both of these provinces had a decrease in their targets (Figure 10). In both Manica and Sofala where targets increased substantially, 18 percent of the targets were achieved. Manicca enrolled more patients in Q1 than in any quarter in FY16.
Figure 9. Number of new patients enrolled in ART compared with target, by province, FY17 Q1
Figure 10. Progress toward the annual target for patients newly enrolled in ART, by province and quarter, life of project
In DSD sites, CHASS achieved just 74 percent of the new quarterly target, with Manica and Sofala below target and Niassa and Tete above target. The pattern was the same in the TA sites, although performance was lower at 64 percent.
22 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
When CHASS compared the number of patients newly enrolled on ART with the number who tested positive, 71 percent (16,805/23,617) of those testing positive were newly enrolled on ART, thus maintaining the level of achievement attained last quarter, which was substantially higher than in the first half of FY16. This quarter, the proportion enrolled ranged from 63 percent in Sofala to 82 percent in Manica.
CHASS has not investigated this pattern below the provincial level, as patients may move between districts and sites, particularly given that not all sites that test patients offer ART. Also, it is not expected that all patients who test positive will enroll, for several reasons: 1) some people test more than once, so the number testing positive does not represent unique individuals (as described above, this explanation is yet to be studied more rigorously); 2) not all people who test positive are eligible for ART in sites not yet implementing Test and Start; and 3) some patients who are eligible do not enroll in care due to stigma or not feeling sick. CHASS has hired and seconded over 60 lay counselors and psychologists to priority sites to improve posttest counseling and treatment literacy. CHASS will also continue training other health workers especially in T&S sites so as to increase knowledge on the benefits of early ART initiation.
Eligibility for ART Using the data collected manually on patients newly enrolled on ART and pre-ART, CHASS can compare the number eligible with the number who started ART. This quarter, 75 percent of all new patients at non Test and Start sites where data were manually collected were eligible to start ART according to the government guidelines and 72 percent started on ART. This is a big improvement relative to past quarters when there was a larger gap. In general, the percent of patients who were eligible for treatment was similar to last quarter (e.g., 87 vs 86 percent in Niassa), however the percent who had enrolled in treatment has increased (e.g., from 63 to 76% in Niassa). The gap still varied by province (Figure 11), ranging from a 6 percent gap in Sofala to a 28 percent gap in Tete. In Manica a higher proportion of patients were enrolled than were eligible. The reason for this over performance is not clear. Unlike in last quarter when classification of all patients was not possible, this quarter, all patient’s eligibility could be determined but as in the past, it is likely that some patients not classified as eligible were in fact eligible. The data from Tete are currently under review and may need to be updated.
23 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 11. Number and percent of new HIV-positive patients eligible/newly initiated on ART in Q1 of FY17*
*Does not include EPTS sites
The same analysis at Test and Start sites without an EPTS showed that of the 1,001 patients enrolled in pre-ART, 86 percent were eligible using standard criteria and 91 percent had initiated in ART. In Manica, all of the new patients had initiated ART and only Niassa had fewer patients that had initiated ART than were eligible. Although we expect all patients to enroll, some may enroll in a different quarter, particularly if they are diagnosed at the end of the quarter.
Currently on ART This quarter is the first time that CHASS is reporting quarterly data on the number of patients currently on ART. In the past, these data have only been reported semi-annually. Across the four provinces, a total of 220,640 patients were reported to be currently enrolled on ART (70,194 in Manica, 19,029 in Niassa, 79,449 in Sofala and 51,968 in Tete). This compares to a reported 230,102 reported at the end of September (64,732 in Manica, 17,981 in Niassa, 98,224 in Sofala and 49.165 in Tete). The loss of patients currently on ART despite substantial increases in the number of patients newly enrolled on ART is the result of three key factors:
1) The handover of four sites in Sofala to other partners (one to the US Department of Defense and three to Santa Egidio). With this handover, CHASS had an automatic reduction of 10,908. 2) The implementation of new EPTS sites. In general, during the transition from paper-based to electronic records, there is a downward correction to the number of patients currently on ART as duplicate files are identified and deleted, data on status are updated, and other cleaning procedures take place. This quarter five sites newly reported the number of patients currently on ART using an EPTS. In these sites, CHASS saw a reduction of 4,801 patients across all four provinces. This was a 44% reduction at these five sites which is larger than expected based on past EPTS implementations. The larger than expected reduction was largely the result of large losses at Macurungo in Beira where 58% fewer patients were reported following the introduction of EPTS and at HP Mutarara in Tete where 42% fewer patients were reported following the introduction of EPTS. 3) In Sofala this quarter CHASS identified issues with the data flow to the EPTS in a number of sites already reporting with EPTS in Q4. These issues in data flow led to information not being fully updated in the EPTS in Q4. In addition a number of sites underwent data cleaning exercises. Reviews 24 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
at EPTS and non-EPTS sites that underwent data cleaning exercises, led to a reduction of an additional 6,535 patients. To address the issues at EPTS sites, a meeting was held with the DPS, the EPTS focal points at all sites, the data entry staff, clinical directors and the CHASS program staff to review the flow and agree upon a functional flow as well as the responsibilities of those involved with the EPTS. The provincial team is now monitoring this to ensure that it is being implemented. In addition and in response to the same issues, the CHASS team with the health facility staff conducted a further review at Mascarenhas, Munhava, HCB, Macurungo and updated the EPTS with data from the pharmacies on drug pick up. The new data entry staff that CHASS is posting to the Super 16 will also help to address these problems at those sites. CHASS is reviewing whether it will be possible to post additional data entry staff to other large sites.
While the above factors account for the bulk of the decrease in Sofala, at other sites the reasons are likely to vary. For example, low retention can lead to a drop in the number of patients currently on ART. CHASS reviewed the results at the site level and identified sites with a decrease in the number of current ART patients. In multiple sites, interviews with clinicians and pharmacists suggest that this apparent decline is the result of seasonal variation as many people relocate to their farms (machambas) at this time of year. The relocation begins in October in most places and may continue until March. Thus, patients who picked up drugs in October and then moved to the machamba are at high likelihood of being counted as LTFU. It is not clear if these patients temporarily abandon care or if they transfer themselves to a nearer to their farms. While a review of trends over time would help to illuminate this issue, CHASS has not collected quarterly data until now and SIS-MA does not have historical data. A qualitative study would also be useful to better understand patient practices during this period and identify ways to ensure their continuation in treatment. CHASS will consider this possibility.
Supporting retention in care and treatment
Data on retention in care are only reported semi-annually, however key actions were taken to address retention rates documented at APR16. These are described above in the introduction to this section.
Grupos de apoio e adesão da comunidade In all provinces, the number of sites with grupos de apoio e adesão da comunidade (community support and adherence groups) (GAACs) and the number of members has increased (Table 5)3. In Manica, GAACs were expanded to 13 additional sites, and the number of members more than doubled from 1,458 to 3,709. Niassa expanded GAACs from four to eight sites and added an additional 48 members. Likewise, Sofala expanded to four new sites this quarter but the number of members declined, due to the data cleanings mentioned under the discussion of the number of patients currently on ART. In Tete, where GAACs have been more widely implemented to date, two more sites added GAACs and approximately 1,000 patients were added. The average number of members per group remains below the guidance at 2.9 (ranging from 2.7 in Tete to 4.3 in Niassa). However, given the effectiveness of GAACs even when numbers are below the suggested number per group, these groups remain a priority intervention for CHASS. Effectiveness of GAACs cannot be assessed in Q1 and Q3 when outcomes data are not collected but we will continue to review this in Q2 and Q4 and to do further analysis of who is benefitting most from GAACs.
3 Data from Sofala are currently being reviewed. 25 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Table 4. GAAC enrollment by province, FY17 Q1 Province # of Members Groups Average facilities size Manica 51 3,709 1,069 3.5 Niassa 8 268 61 4.3 Sofala 43 4,839 1,720 2.8 Tete 65 12,368 4,498 2.7 TOTAL 167 21,184 7,348 2.9
Pediatric Antiretroviral Therapy
The CHASS pediatric treatment activities aim to improve case identification, treatment, and retention of HIV-positive children in care and treatment. CHASS uses a three-pronged strategic approach to achieve the above objectives: 1) identification of HIV-infected children/adolescents, 2) linkage of confirmed HIV- infected children/adolescents to ART clinics, and 3) initiation and retention in ART. To identify 90 percent of all HIV-positive children in the catchment areas of supported HFs, CHASS uses the See, Ask, and Test strategy — in which each pediatric encounter, whether in HFs or through outreach activities (e.g., outreach immunization), is an opportunity to screen for HIV exposure and infection.
During the quarter, CHASS technical teams continued to perform pediatric treatment-related cascade analyses - from diagnosis to treatment and retention to identify leakages and develop interventions to efficiently address them. Key interventions implemented this quarter include: Index case testing of children of newly diagnosed PLHIV Deploying additional staff at consultation, triage units, CCR and wards in priority HFs to reinforce the See, Ask and Test strategy and escort HIV positive pediatric clients between HTC and Care units Ensuring initiation of HIV positive children on ART within 15 days from the day the HIV diagnosis is known Facilitating activistas for aggressive tracing of children in communities as soon as their EID results are received at the HF Ensuring recording of correct address of PBFW to facilitate contact tracing Supporting expedited processing of EID samples at Ponta Gea lab—turnaround time was reduced from 45 to 15 days Training maternal and child health (MCH) nurses in polymerase chain reaction (PCR) testing Mentoring HF workers on opening of clinical records at the point of HIV testing Daily monitoring of HIV positive cases identified and ensuring that they are link to ART units for initiation especially high volume HFs. This paid off significantly in Manica
During the quarter, overall 85 percent of exposed infants were tested within 12 months, using the number of pregnant women seen in ANC as the denominator.4 This percentage ranged from 79 percent in Manica to 92 percent in Sofala. Given the higher-than-expected coverage last quarter, which was likely due in part to past tests being reported in Q4, it is not possible to compare these results to Q4
4 This is estimated based on the number of infants tested and the number of HIV-positive pregnant women seen in ANC, which is used as an approximation of the number of exposed infants. 26 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
results. Relative to the quarterly target for infant testing (Figure 12), CHASS was on track overall (at 87 percent of the quarterly target) but below target in Sofala (83 percent) and Tete (80 percent). The number of infants tested decreased relative to Q4 in all provinces, with decreases ranging from 6 percent in Sofala to 41 percent in Tete — more than offsetting the gains seen in Q4. The reasons for the declines vary. In Sofala, this is due to poor linkages between postpartum consultations and CCR units. Steps have been taken to address this at Macurungo in Beira City, focusing on following HIV-positive women through ANC to delivery, postpartum care and CCR. In particular, a community case manager was added in the ANC unit to list and track eligible patients through to CCR.
Figure 12. Number of infants born to HIV-positive women who received an HIV test within 12 months of birth, FY17 Q1
The number of test results received relative to the number of tests done fell again this quarter, to 47 percent from 55 percent in Q4. Fifty-eight percent of all sites reporting PCR testing (N=280) had not received any results, while 35 sites had received 100 percent of the expected number of results. The main reason for this is that many samples that have been sent to the reference laboratories have not been validated and entered into the national PCR database. CHASS has recruited a staff member who will be posted at the reference lab in Beira to support the entry of data into the database and ensure follow-up of samples. At the same time, these data do not reflect the full number of results received to date, as there is a backlog in registering the results received following the concerted efforts to test all samples.
Achieving pediatric targets will require not only testing infants in the first year but also testing young children and adolescents. The percent of people tested who were children varied by sector, with 28 percent of those tested in C-HTC, 25 percent of those tested in PICT, and 9 percent of those tested in UATS being under the age of 15 years. This is roughly the same proportion in each group as in the past, with some increase in C-HTC.
With regard to initiating pediatric patients on ART, CHASS has shown steady improvement since Q2 of FY16 (Figure 13). Again this quarter, CHASS saw increases relative to last quarter in Manica and Niassa, but performance in both Sofala and Tete declined. In Sofala, this decline is largely due to the fact that CHASS is no longer supporting four sites that were responsible for more than 10 percent of all children enrolled last quarter. On the other hand, in Manica the team focused on larger sites (particularly 1º Maio CS II, 7 de
27 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Abril, Eduardo, Mondlane CSURB, Nhamaonha CS II, Gondola Sede CS I, Manica CS I, and Sussundenga Sede PSA) and allocated additional staff at the triage units to improve PICT of children. These sites have also added daily monitoring of HIV-positive cases and linkage to ART initiation. Although these sites have always been responsible for a large percentage of the children enrolled in Manica province, their relative percentage has increased from an average of 34 percent in the first three quarters of the year to 45 percent in the past two quarters. These same sites have also seen increases in adult enrollments, but the magnitude of the change has been smaller (from an average of 38 percent to an average of 43 percent).
Relative to targets, all Ped ART targets were below an acceptable level of performance this quarter (below 85 percent of the quarterly target), in part because of a 41 percent increase in the target (ranging from 10 percent in Niassa to 76 percent in Sofala). To address this massive increase in Sofala, CHASS will implement the successful strategies already in use in key sites in Manica (discussed above); CHASS will also collaborate with the CoVida project in Marromeu and Buzi districts and with World Education in Beira City and Dondo district to improve linkages for youth and develop intra-community synergies for treatment support for orphans and vulnerable children (OVC), with CHASS providing testing services and CoVida and World Education providing comprehensive support services to OVC. CHASS will also strengthen the case index approach to testing in both communities and HFs to the extent possible.
Figure 13. Number of children with advanced HIV infection newly enrolled on ART, by project over the life of the project 1,600 1,324 1,350 1,400 1,238 1,222 1,200 1,026 1,000 800 600 400 200 0
# children # enrolled newly ART on Q1 Q2 Q3 Q4 Q1
CHASS Manica Niassa Sofala Tete
Challenges related to Care and Treatment
Limited success in tracing and returning pre-ART PLHIV for inclusion in ART in T&S sites as well as the context of new elibility guidelines. The main challenges are wrong contact information and relocation from the last recorded address. It is believed that widespread rollout of T&S, aggressive case management and early home visits will gradually address the challenge. Although CHASS deployed more staff in HFs to strengthen psychosocial support to PLHIV and thus enhance treatment adherence and retention, the newly recruited staff require continuous training, thus it may time some time before a significant impact is observed.
28 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Even with T&S, there are still delays in initiating PLHIV on ART due to several factors such as stigma, disclosure, not feeling sick, and perceptions that ARVs have side effects. This requires continuous mentoring and supportive supervision of HF workers as well as effective counselling to PLHIV
Major activities for the next quarter
. Support rollout of Test and Start in the new 11 Sites in phase 2—from February 2017. . Intensify TA to the districts that were previously not reachable due to insecurity . Continue aggressive case management of newly diagnosed PLHIV and escorted referrals to reduce leakages between HTC and C&T so as to increase the number of PLHIV newly initiated on ART . Train staff newly seconded to priority HFs to enhance effective counselling and psychosocial support of PLHIV P . Strengthen operationalization of VL by ensuring that clinical staff request VL for all eligible patients
29 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Laboratory Services
CHASS support for laboratory services focuses on strengthening diagnostic and patient monitoring capacities of HFs to enhance HIV case identification, initiation of eligible PLHIV on ART in a timely manner, switching of treatment regimens, and managing opportunistic infections. Support for laboratory services is therefore key to achieving the project’s HTC, PMTCT, ART, and TB objectives and targets.
HIV testing
During Q1 of FY 17, CHASS continued to provide material assistance and TA to ensure that PEPFAR- supported HFs have the capacity to provide HIV serology testing in accordance with MISAU guidelines. HTC lab support also contributes toward achieving the first of the 90:90:90 UNAIDS goals, which seeks to increase HIV case detection. Accordingly, in addition to supporting HIV testing within the main hospital labs, CHASS teams supported HIV testing in the different service delivery points including TB, ANC, wards, and CCR so as to enhance PITC. During technical support visits (TSVs), CHASS lab staff checked the availability of RTKs, HTC registers, and national guidelines and mentored HF workers on how to optimize their use.
Operationalization of viral load testing
During the quarter, CHASS supported the MISAU in rolling out viral load testing in Manica and Sofala provinces. The testing began in Mainica, November, and Niassa in December 2016. This made viral load services available in all four provinces supported by CHASS. CHASS’s support included reproducing and distributing viral load registration books and request forms to all district headquarters in the provinces. In addition, CHASS assisted Niassa, Tete, and Manica DPSs to purchase three printers to be installed in the laboratories of the respective provincial hospitals (i.e., Lichinga, Tete, Chimoio). The printers will be connected to the network with the reference laboratories in order to speed up transmission of viral load test results to district and HFs. Presently, Sofala viral load samples are processed at the Ponta Gêa Lab in Beira, Manica samples at the Dream Lab in Beira, and Tete samples at the Quelimane Molecular Biology Lab, and Niassa samples at the Nampula Molecular Lab.
In the past three months, Ponta Gêa Lab processed 2,476 viral load samples as compared with 949 samples from July to September 2016, representing an increase of 61.7 percent. Turnaround time remains a challenge. Of the 840 samples collected from HFs in Manica and sent to the Dream Lab in Q1, only 209 results were returned, which corresponds to 25 percent of the samples sent. From Tete, of 3,539 samples sent to Quelimane, only 1,105 results were received (31.2 percent). Out of the 495 samples collected from Niassa and sent to the Nampula Lab in the first week of December, no results had been achieved by the end of the month. CHASS will continue working with all stakeholders to find a solution to this challenge.
CHASS is working to adapt to the new viral load indicators, which require that the result be linked to the patient record, and will provide data on the coverage of ART patients in the next quarterly report.
30 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Support for polymerase chain reaction testing
CHASS continued to support early infant diagnosis (EID) using both point of care in some HFs and the polymerase chain reacton (PCR) labs. During the quarter, 5,779 samples were collected and sent to the designated reference labs. This is a decrease of 47.2 percent when compared with the 8,510 samples collected, processed, and sent to reference laboratories in Q4 of 2016. The reduction is attributed to the Christmas holidays, when most activities generally slow down. From all the results received, 8.35 percent were positive. The positivity rates varied by province, with Sofala at 11.2 percent, Manica at 11.3 percent, Tete at 4.9 percent, and Niassa at 7.3 percent.
Support for improving TB case detection
CHASS supported the installation of two Gene Xpert appliances in Manica and Mossurize district hospitals. Additionally, CHASS lab staff disseminated the MISAU circular that urges HFs to maximally use the equipment to increase TB case detection. The team mentored HF workers on how to use, optimize, and maintain the equipment. During the quarter, 7,395 samples were tested using Gene Xpert equipment, compared with 6,004 in the previous quarters showing an increase of 18.8 percent.
Strengthening quality assurance/quality control
The CHASS lab team continued to provide on-the-job training and mentoring on standards of good laboratory practice including quality system management, biosafety, and equipment maintenance. Also, SOPs were made available to technicians, which facilitated the updating of existing procedures in laboratories that were outdated. In Sofala, the focus of the TA was on supporting Ponta Gêa Lab in processing accumulated PCR samples, viral load testing, revising the database (DisaLab), and printing and routing of available PCR and viral load results to health units. CHASS hired and seconded two Lab Technical Officers to Ponta Gea optimize operations to the lab. In Manica and Tete, the main activity was training laboratory technicians in supported HFs. Topics covered included standards of good laboratory practice, quality system management, biosafety, and equipment maintenance. More than 20 staff participated in the training. Additionally, the Tete lab team reproduced and distributed 200 HIV testing algorithms to health units. At the central level, CHASS, represented by the senior laboratory officer, participated in viral load, HIV testing, and quality improvement technical working groups organized by MISAU.
Activities for the next quarter . Operationalize the printing of viral load results in the laboratories of the provincial hospitals of Manica, Tete, and Niassa. . Train laboratory more technicians, maternal and child health (MCH) nurses and other clinicians in the collection of viral load samples in all HFs of the province. . Ensure the printing and delivery of PCR and viral load results to the HFs. . Support the installation of the DISA Link program in the laboratories of provincial hospitals for the management of samples and results. . Continue to provide TA to laboratories in order to continually improve quality. . Work with FHI 360 to establish quality control measures in some supported ART sites/labs
31 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Pharmaceutical Care Systems and Services
During Q1 of FY17, CHASS continued to strengthen pharmaceutical management processes to minimize stock-outs, improve quality of consumption reports, and reduce losses and expiry. Additionally, CHASS supported the strengthening of pharmacovigilance (PV) systems to improve patient care.
Strengthening drug and commodity management at provincial/district warehouses and in HFs
CHASS continued to support drug and commodity management by promoting optimal medicines management practices, mentoring HFs for accurate consumption reports, and preventing stock-outs.
Training and mentoring of pharmacy technicians on drugs and commodity management: During the quarter, CHASS pharmacy teams mentored and performed on-the-job training for 82 pharmacy technicians (Sofala: 9; Manica: 12; Tete: 48; Niassa: 13) in 37 HFs, direcção distrital de medicamentos (district drug directorates) (DDMs), and direcção provincial de medicamentos (provincial drug directorates) (DPMs) in the four provinces (Annex 2 and 3). The training and mentorship focused on standard operating procedures for updating stock cards, accurate and timely updating of daily antiretroviral registers (LRDAs) and individual patient drug pick-up records (FILAs), and antiretroviral (ARV) and RTK consumption data report forms (MMIAs) from both the service delivery points to the pharmacy and from the pharmacy to the DDM/DPM. Additionally, CHASS pharmacy teams continued to provide TA through TSVs. The TA covered various aspects of drug commodity management including: Updating of stock and inventory status for health commodities using existing tools. Accuracy and timeliness of commodity consumption reporting (e.g., LRDA, MMIA). Implementation and management of SIMAM system at the DDMs and DPMs. Execution of health commodities distribution plans. Support for health commodities distribution: During the quarter, CHASS supported the distribution of health commodities directly from the provincial level to the district level and from the district to the respective HFs. CHASS technical personnel supported the preparation and review of monthly distribution plans from the DPMs to the DDMs. CHASS also provided financial resources to the DPSs in Tete and Niassa to facilitate transportation of the commodities to the various district-level warehouses. As a result, no HF reported stock out of ARVs or RTKs during the quarter. In Manica and Sofala, CHASS has been working with the Clinton Health Access Initiative (CHAI) to support drug distribution in the two provinces. Unlike in Tete and Niassa, the transportation of health commodities is outsourced. With the end of CHAI distribution support in the two provinces, CHASS has been working with the DPSs and CHAI to source for alternative providers through open competition. At the end of the reporting period, the process was ongoing.
Consumption reporting for ARV drugs and RTKs: There were few incidents of delayed MMIA reporting during the period October through December. Tete province had four facilities (i.e., Cahora Bassa, Mágoe, Angonia, Marávia) with reported delays ranging from one to four days. The delays were attributed to transport challenges and poor organization of the DDMs in some cases, thereby delaying SIMAM system updates. To prevent future occurrences, the technicians at the affected HFs were advised to scan and send the MMIAs using available phone applications pending the physical delivery of the reports.
32 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Implementation support for SIMAM logistics management system: During the quarter, CHASS pharmacy teams provided support for the operation of the SIMAM logistics management information system in 15 DPMs/DDMs and HFs in the four CHASS provinces. Presently, the SIMAM system is installed at the provincial (DPM) and district (DDM) warehouses as well as in some provincial hospitals. The support involved technical and material support (i.e., provision of maintenance services and consumables including Internet facilities) in the timely updating of consumption data from HFs as well as medicine distribution schedules. There were no major technical or operational problems reported during this review period.
Implementation of electronic drug management system: In FY17, CHASS is working to procure and implement an electronic drug and medicines management system targeting 25 HFs that currently have more than 2,000 patients on ART. Electronic systems will ease the dispensing process, improve drug management and the quality of the consumption and defaulter data reports, and improve adherence through reduced patient waiting time. Additionally, CHASS will roll out a mobile-based MMIA-reporting system targeting difficult-to-access HFs to facilitate the timely submission of consumption data to the DPMs. At the end of the reporting period, the procurement process was in progress with delivery expected during Q2. CHASS is also in discussions with MISAU and other U.S. government partners to identify a tested and currently implemented system that can be linked with the existing electronic patient tracking system (EPTS). The identification and selection process will be finalized during Q2. Decentralization of ARV distribution and dispensing To assist in reducing patient numbers at the pharmacy, CHASS is working toward establishing peripheral drug-dispensing outlets among the FARMAC chain of community pharmacies. CHASS is currently working on a study to determine the acceptability and feasibility of using these community pharmacies in the provinces as dispensing points. The protocol is being finalized for presentation for institutional review board approval. Support for the three-month dispensing initiative MISAU is implementing a three-month dispensing strategy in two facilities in each province with the aim of decongesting the pharmacies, reducing the need for patients to travel to the HFs, and reducing waiting times for patients, therefore enhancing adherence and retention. During the period under review, CHASS-supported HFs enrolled 3,621 patients, bringing the total enrolled since the intervention started to 7,885. This represents 22.8 percent of the active patients in these HFs. Table 6 illustrates the number of patients on three-month dispensing in the participating HFs.
Table 5. Number of patients enrolled in three-month dispensing in the HFs Province Health Facility Total FY17 Q1 Total Overall % of Total Active Patients Manica 1a Maio 555 1197 18.8 Eduardo Mondlane 703 1167 19.9 Niassa Cidade de Lichinga 319 533 21.8 Chiuaula 146 316 27.5 Sofala Ponta Gea 494 880 14.4 Nhamatanda 195 272 23.0 Tete CS 3 325 769 15.5 Moatize 884 2751 42.5 Total (Participating HFs) 3621 7885 22.8
33 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
During implementation, some patients who may have been eligible for three-month supplies were being missed by the clinicians during clinical consultation. Some patients also missed the criteria, mainly due to lack of CD4 results on file. Additionally, some enrolled patients were not properly identified (through the prescriptions) at the pharmacy level and therefore were not captured in the pharmacy records. To address these gaps, CHASS teams:
Continuously engaged with the clinicians in these HFs during TSVs by the clinical zonal teams and together agreed on steps for reducing missed opportunities. Initiated joint (CHASS and HF staff) regular pre-consultation patient file reviews and classification per the eligibility criteria, and marked the appropriate files for attention from the attending clinicians. Provided job aids, table-top references with the criteria, provision of rubber stamps for marking prescriptions to allow easier identification at the pharmacy level, and separation of FILAs for patients using three-month dispensing at the pharmacies.
Strengthening the use of FILAs to identify and track defaulters CHASS pharmacy teams continued to support the accurate and timely updating of pharmacy-based patient tracking records and FILAs in 44 HFs (Tete: 18, Sofala: 14, Niassa: 6, Manica: 6) with a view of providing accurate information on defaulting ART patients (Annex 4). This has been a challenge, especially in the high-volume sites where the available pharmacy personnel are overstretched and in many cases unable to update the records daily as per the standard operating procedure. This has led to a situation in which some patients are classified as defaulters when they are not. Additionally, the methodology of completing the FILAs and LRDAs has changed in facilities where the three-month dispensing is being implemented. To strengthen this, CHASS pharmacy teams: Provided direct support in daily updating of the records at the pharmacy. Engaged available human resources including the pharmacy technicians, support staff, and students in updating the records after hours and/or during the weekends. Triangulated data in service delivery points with EPTS data, where available, to ensure that records are updated and the defaulter lists that are generated are accurate.
Promoting and supporting PV and patient safety In collaboration with the provincial PV focal persons, CHASS continued to support the PV system at the provincial level through on-the-job training and TA in the identification and reporting of ART-related side effects. The personnel provided with on-the-job training at the HFs included pharmacy technicians and nurses involved in ART care.
Improving and supporting adverse drug reaction notification: During Q1, 983 adverse drug reaction (ADR) notifications were received from the four provinces out of a target of 1,038. This represents 94.7 percent of the overall targets. By province, Sofala and Manica performed above the target (113.4 percent and 159.2 percent, respectively), while Tete and Niassa were slightly below target (81.4 percent and 84.8 percent, respectively) (Figure 14).
34 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 14. ADR notifications rates by province, FY17 Q1
Implementation of a patient-focused PV package for health care providers: The patient-focused PV training and intervention package is meant to support clinicians in the use of ADR data to improve management of patients at the HF level, patient safety, and treatment outcomes. During the quarter, CHASS in collaboration with the division of PV at MISAU organized a training of trainers workshop bringing together 35 clinicians and pharmacists from Sofala, Manica, Tete, and Niassa (DPS and CHASS) as well as the division of PV. The aim was to provide a set of trainers that will step down the training at the provincial level, thereby enabling clinicians to use recorded ADR data to improve individual patient management and help reduce similar preventable ADRs in other patients. The provincial level trainings are scheduled for Q2. Support for national pharmacy-related activities CHASS participated in several technical working groups and meetings at MISAU including: CMAM partners meeting: discussed the CMAM plans and budget for 2017 and available partner support in the area of medicines logistics. TB drug quantification technical working group: quantified TB drug requirements for both drug sensitive and drug-resistant TB (MDR/XDR-TB). The HIV technical working group on “Test and Start” and three-month dispensing initiatives: preliminarily evaluated the Test and Initiate and three-month dispensing initiatives and resolved for better reporting of consumption of ARV drugs and RTKs as well as the need for adequate medicine storage facilities, as the drug requirements at the HF level increases with the rolling out of the initiatives.
Major pharmacy activities for the next quarter Intensify support for rolling out the three-month dispensing initiative in the approved HFs through zonal teams. Additionally, we will advocate for the expansion of the initiative to other high-volume sites, particularly those implementing Test and Initiate. Finalize the selection of the electronic drug management system for implementation. Organize training and implementation of patient-centered PV at the provincial level and target implementation in the priority HFs.
35 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Prevention of Mother-to-Child Transmission Mother-to-child transmission is the primary mode of HIV acquisition in children, accounting for about 90 percent of cases. Therefore, the most efficient and cost-effective way to tackle pediatric HIV is to eliminate mother-to-child transmission. To contribute toward this goal, CHASS supports MISAU, DPSs, and SDSMASs to increase coverage of PMTCT services in scale-up districts. Additionally, CHASS PMTCT activities focus on 1) rolling out Option B+ to contribute toward the national target of reaching more than 90 percent of HIV-positive pregnant women, 2) increasing 12-month retention on ART among HIV- positive pregnant and breastfeeding women, and 3) improving follow-up of HIV-exposed infants with the target of covering 90 percent of them with cotrimoxazole preventive therapy and 90 percent with access to EID.
During the first quarter of FY17, the CHASS clinical teams focused on addressing gaps identified in FY16. Major PMTCT activities undertaken during the quarter included: Facilitating creation and reactivation of mother-to-mother support groups and training mentor mothers in priority HFs so as to enhance adherence counseling and retention. Training MCH nurses to improve EID management. The training covered dried blood sample and viral load sample collection and referral as well as using EID results to initiate HIV-positive children on treatment. The training aimed to increase HIV case identification among children as well as increase the number of HIV-positive children on pediatric ART. The trainings targeted sites with high rates of sample rejection. Supporting male involvement in PMTCT services. CHASS supported CBOs to implement sensitization activities at community levels. Distribution of information, education, and communication (IEC) materials and facilitation of HF workers for PMTCT-related community talks, highlighting the importance of men in PMTCT and MCH generally, were also supported.
CHASS technical teams continued supporting efforts for rolling out Option B+ PMTCT services and improving EID testing. Within the three-month period, 29 additional HFs supported by CHASS began offering Option B+ (11 in Manica and 14 in Niassa), 12 of which were new sites that had not previously received support from CHASS for ANC. This surpassed the target of 19 new HFs with Option B+ in FY16, expanding to a total of 37 new sites. The target for FY17 is 75 sites offering Option B+ services. CHASS supported the expansion through training and mentorship on the new guidelines; provision of updated MISAU-approved materials on Option B+, including algorithms, job aids, and IEC; and provision of basic supplies like chairs and privacy partitions to facilitate the work. Additionally, CHASS country office senior technical officers for PMTCT and pediatric ART spent considerable time in Manica and Sofala provinces working with the provincial teams and the DPSs to address under-performance with regard to testing of infants. Data for Q1 show significant improvements.
As in FY16, CHASS was on target in Q1 of FY17 with regard to the number of women registered in ANC. Between October and December, 96,970 women enrolled across all sites. The number registered was about the same as that from last quarter (a slight increase of just more than 1,100 women across all four provinces). Overall, 97 percent of these women knew their HIV status (Table 7 — a vast improvement from 88 percent in Q3 when the new MCH registers were introduced and the staff were unfamiliar with completing them, and a small improvement from Q4 when coverage was 95 percent. CHASS is continuing to work with the DPS in each province and with HF staff to develop their capacity to accurately complete and summarize the new tools.
36 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Among all of the women registered, 7 percent were known to be HIV-positive (about the same as last quarter); this percentage has ranged from 6 to 8 percent over the life of the project. Performance across the PMTCT cascade remained strong this quarter at the project level, especially in terms of enrollment of HIV-positive women in care (Figure 15). Different components of the cascade are discussed in detail below.
Table 6. Performance of key PMTCT indicators by province, FY17 Q1 Target Achievement % of pregnant women with known HIV status 100% 97% Manica 100% 99% Niassa 100% 96% Sofala 100% 96% Tete 100% 95% % of HIV-positive pregnant women who received ARV drugs to reduce risk of 100% mother-to-child-transmission 97% Manica 100% 97% Niassa 100% 94% Sofala 100% 98% Tete 100% 97%
Figure 15. PMTCT cascade, FY17 Q1
In terms of the number of pregnant women registered, CHASS was on target in DSD sites but only achieved 62 percent of the target in TA sites this quarter. This is consistent with performance in FY16.
Overall, 97 percent of registered women this quarter (93,488) had a known HIV status — a continued improvement relative to the past two quarters. However, only Manica achieved the expected 99 percent coverage. This was a substantial improvement in Manica, where coverage was 90 percent in Q4. This change can be attributed to the considerable support from the country office and the engagement of more than 50 temporary staff to support HFs in various areas. This quarter, just 11 percent of sites reported less than 90 percent — roughly the same level seen in Q2 of FY16, before the new tools were introduced. All sites with less than 90 percent coverage are listed in Annex 1c; these sites will be given additional follow-up in Q2, especially the 17 DSD sites on this list. Some of these sites also had low 37 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
coverage in Q4 and will receive visits to address this. These sites are Niassa / Cuamba / Napacala PS, Niassa / Mecanhelas / Chissaua PS, Niassa / Mecanhelas / Chiúta PSA, Sofala / Caia / Murraça CS III, Tete / Angonia / Catondo, Tete / Tsangano / N'Tengo Wambalane PS.
Overall, the positivity rate in ANC settings this quarter (in the four provinces) was 7 percent. Although this was lower than in the past two quarters, the provincial positivity rates increased from 4 to 5 percent in Niassa and Tete, and remained constant in Manica (7 percent) and Sofala (10 percent). Twenty-nine facilities reported no HIV-positive women in ANC — a slight increase from last quarter — and as in the past two quarters, 45 percent of ANC sites reported that less than 3 percent of pregnant women were HIV-positive. At the other end of the spectrum, only 10 facilities (Annex 1) reported positivity rates of more than 20 percent, down from 12 in Q4, 16 in Q3, and 21 in Q2. An additional 19 sites had positivity rates above 15 percent this quarter, and 10 of them have had rates above 15 percent for four out of the five quarters, with CHASS support. A handful of sites had notably higher positivity rates this quarter than in the past. This may be attributed to interventions implemented to improve the quality of HTC, including training of MHC nurses and rolling out of the MISAU quality improvement (QI) program in the quarter.
In addition to testing women who come for ANC and maternity services, PMTC services aim to test the partners of these women. A total of 23,109 partners were tested this quarter, meaning that partners of 24 percent of women registered were tested. The coverage of partners was lower in Manica (9 percent, n=2,173) and Sofala (11 percent, n=2,508) and higher in Tete (34 percent, n=9,740) and Niassa (46 percent, n=8,688). Overall, positivity rates are low among partners who are tested (4 percent, range 3 to 6 percent) and are, in fact, lower than among the pregnant women registered.
This quarter, 97 percent of HIV+ pregnant women received ARV drugs — a continuation of the increase seen last quarter. Coverage ranged from 94 percent in Niassa to 98 percent in Sofala. Sub-provincial analysis is complicated by the fact that women may not have access to Option B+ in their own district but may receive Option B+ in a more central location. Overall, this represents the highest level of coverage attained over the life of the project, both at the aggregate level and in all provinces except Sofala, where coverage declined by 1 percentage point relative to last quarter (Figure 16). However, Sofala still had higher coverage than all other provinces.
Figure 16. Option B+ coverage among HIV-positive pregnant women, by province and quarter 100% 98% 99% 98% 96% 97% 97% 95% 95% 95% 93% 93% 94% 90% 91% 91% 89% 89% 87% 87%88% 85% 85%
80% 79% 75% 70% 65% 60% Y16 Q1 Y16 Q2 Y16 Q3 Y16 Q4 FY17 Q1
Manica Niassa Sofala Tete Total
38 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Comparing the number of children under 1 year old who were tested for HIV via either PCR or rapid test to the number of HIV-positive pregnant women, 86 percent were tested — a decrease from the level seen last quarter. The reason for greater than 100-percent coverage likely reflects the implementation of the See-Ask-Test approach under which at-risk children aged 18 to 24 months were identified who had not been tested; these children were tested in CCR, but there is no way to differentiate the age of these children using the current tools. Among those children tested this quarter, just under 5 percent tested positive for HIV — a slight decrease from more than 5 percent last quarter. Among infants tested with PCR, 4.9 percent tested positive. However, just 47 percent of the number of infants tested had results recorded at the HFs — the same level seen last quarter. Although this is a dramatic increase from 29 percent last quarter, it highlights the ongoing problems with the PCR system. In the last quarter, the CHASS team worked to ensure that results from the backlog of tests that had been processed were entered at HFs.
Challenges related to PMTCT
Inadequate and poor quality data in some HFs due to inadequate documentation of services and poor filling of MCH registers. This is mainly due to high levels of work overload. CHASS is seconding MCH nurses and other cadres of health workers to ameliorate the problem in high-volume sites.
Ensuring that HIV-positive infants are enrolled in care and treatment remains a challenge, both because of delays in getting test results (due to incomplete or wrong recording of test results) and caregiver addresses. The CHASS clinical team is working with the community team to strengthen psychosocial support of caregivers to prepare them for treatment, to improve contact tracing and busca activa for infants, and to escort all infants with positive results from CCR to ART services.
Key PMTCT activities for the next quarter
Continue supporting with reactivation and creation of mother-to-mother support groups and training of mentor mothers in the 16 high-volume focus HFs. Continue with on-the-job training of MCH nurses in psychosocial support and positive prevention to improve retention in PMTCT and ART. Support CBOs to implement more creative activities to strengthen male involvement in PMTCT and ART generally. Roll out operationalization of viral load testing for PBFW in the four provinces.
TB/HIV Integration
To mitigate the potentially fatal effects of TB/HIV comorbidity, CHASS emphasizes the importance of TB/HIV collaborative activities across all supported sites, focusing on increasing early TB case detection and treatment among PLHIV. Interventions include 1) intensified TB case finding among PLHIV; 2) HIV testing among TB patients; 3) institutionalizing infection prevention and control; 4) isoniazid preventive therapy, including ART for people co-infected with TB; and 5) strengthening HF and community linkages for effective TB case management. 39 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
CHASS clinical teams continued to strengthen the capacities of HF providers in managing TB/HIV co- infection. This was done through on-the-job training and mentoring during TSVs. Topics covered included counselling, HIV testing, initiation of ART within two weeks of TB diagnosis, cotrimoxazole prophylaxis (CTZ), chemoprophylaxis, following up results for smear tests, and routinely and correctly completing patient files and registers.
In line with MISAU guidelines on the massive use of Gene Xpert, Niassa province mentored HF providers on using the equipment where available, and this resulted in an increase in new TB cases identified in Cuamba, Lichinga, and Marrupa HFs. A total of 950 patients were diagnosed during the quarter, representing an increase of 32 percent from cases reported in the same province in Q4 of FY16.
The TB cascade (Figure 17) provides an overview of project performance with regard to patients co- infected with TB and HIV. This quarter, 6,452 TB patients were registered, and 100 percent of them were tested for HIV. Overall, 37 percent (2,364) were HIV-positive — a slightly smaller proportion than in Q4. Furthermore, 95 percent (2,236) of co-infected patients had started on cotrimoxazole, and 87 percent (2,058) has started on ART — an increase from 80 percent in Q4. As in Q4, the percent positive continues to be lower than expected (37 percent versus 51 percent; range of 20 percent in Niassa to 48 percent in Sofala).
Figure 17. TB cascade, FY17 Q1
This quarter, performance in the number of TB patients registered was within an acceptable range with regard to the quarterly targets in all provinces (range of 94 percent in Sofala to 121 percent in Manica) except Sofala, where it fell to 80 percent of the target despite having only a 10 percent increase in its target (Figure 18). The challenge has been traced to centralized registers at the district level, where TB patients from peripheral HFs are recorded. There is a time lag from case identification to completion of registers. This level of performance is similar to that seen prior to Q4.
40 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 18. TB patients registered, by province and quarter 7,000 6,452 6,046 6,000 5,345 4,934 4,932 5,000 4,000 3,000 2,000
1,000 # registered registered # in the TB sector 0 Q1 Q2 Q3 Q4 Q1
CHASS Manica Niassa Sofala Tete
The number of TB patients registered increased from Q4 to Q1 in Manica and Niassa but declined in Sofala and Tete (ranging from a 7 percent decrease in Sofala to a 32 percent increase in Manica). Whereas in FY16 the number of TB patients registered increased in Manica, Sofala, and Tete and remained more or less constant in Niassa, this quarter there were substantial increases in Manica (23 percent) and Niassa (32 percent) and slight declines in Sofala (7 percent) and Tete (2 percent). In Tete, two sites (Boroma and Changara HCs) were inaccessible due to insecurity, so there were no data reported. In Sofala, where the number registered declined by 7 percent, this was the result of CHASS no longer supporting sites receiving support from St Egidio; almost 10 percent of all TB cases registered in Sofala last year were registered at these sites. In other provinces where sites were added or dropped (Manica and Tete), this had relatively little impact because the numbers of patients at these sites were small. For example, although Manica added a site that composed 2 percent of the TB patients registered this quarter, there was a 23 percent increase in the province as a whole. In Niassa, during the quarter, the CHASS provincial team assigned targets to HFs so as to increase TB case detection, carried out a community campaign to promote TB testing and collect specimens for testing TB suspects, and mentored HFs to request a TB test for every patient with cough symptoms during consultations.
This quarter, among new TB patients registered, 37 percent knew their HIV status at entry and 99 percent of those who did not were tested for HIV — about the same as last quarter. Among those newly tested, 15 percent (495 patients) were HIV-positive, and overall 39 percent of the newly registered TB patients were HIV-positive (Figure 17). In 101 (93 percent) of the 109 facilities reporting new TB patients in the quarter, at least 97 percent of TB patients knew their status. This is a further improvement relative to last quarter, when 89 percent of facilities reported that 97 percent or more of TB patients knew their status, which was also an improvement compared with 83 percent in Q3. However, two more facilities had less than 91 percent of patients with a known status. Overall, very few patients (n=57) had an unknown status; again, Inhaminga HR in Sofala was responsible for more of these cases than any other facility. It is the only site that has low coverage (below 97 percent both last quarter and this quarter). Unfortunately, the staff who were trained to rectify the problem were transferred to another unit, implying that the problem will take longer to solve, as CHASS has just completed training the replacement staff.
41 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
In terms of where HIV-positive patients were identified, the positivity rates among new TB patients ranged from 0 percent (eight sites) to 100 percent (one site), with an average of 35 percent of new patients co-infected with HIV. Twenty-four sites were responsible for 69 percent of all newly positive patients identified through the TB sector and will be prioritized for TB/HIV services. This is the case in part because these sites registered half of all new TB patients, but also because they over-represent the number of co-infected patients in comparison to their patient volume. Unlike last quarter, when there was a bigger difference in the overall positivity rates between these sites and all other sites combined (48 percent versus 35 percent) than there was in positivity rates among those patients who were newly tested (32 versus 18 percent), this quarter the gap was the same, suggesting that the difference at these sites is not attributable to better screening of HIV-positive patients. Eight of these sites were also big contributors to the number of patients with HIV in the TB sector (Annex 1a). Lessons learned from these sites will be identified.
Challenges Initiation of ART within 15 days in patients with a TB diagnosis and the referral of TB co-infected patients to HIV clinics once TB treatment has been completed are major challenges faced in TB/HIV integration.
TB and HIV services are not always offered in the same peripheral HFs, necessitating referral of patients to obtain appropriate care in other sites where it is available. Often times, transport costs become a challenge, thus contributing to loss of eligible patients to start ART.
Implementation of infection control measures remains a huge challenge in the four provinces due to difficulties associated with remodeling the available infrastructure. CHASS will use the upcoming HF renovations activity to address the need for remodeling, where it is possible and within compliance limits.
Key TB/HIV activities for the next quarter
Continue mentoring HF providers to accurately fill clinical files in TB registers. Monitor and support HFs to ensure that ART is offered within 15 days of diagnosis of TB. Continue advocating with DPSs to adopt the one-shop care model to enable sites to provide integrated TB/HIV services. Due to high turnover of providers, CHASS teams will continue on-the-job training and mentoring on TB/HIV management. Ensure that guidelines and job aids are distributed.
Nutrition Support
The CHASS nutrition support program aims to strengthen nutritional care for PLHIV in clinical and community-based services in accordance with the national guidelines. The project supports the implementation of the Nutrition Rehabilitation Program volumes 1 and 2. Emphasis is placed on screening PLHIV for malnutrition, nutrition counseling, and nutrition support using corn and soy blend plus supplementation provided by other partners. CHASS also supports the rollout of the Baby-Friendly
42 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Hospital Initiative of MISAU. ART, TB, PMTCT, and CCR service delivery units are entry points to diagnose HIV-positive patients who are clinically malnourished and need supplementary or therapeutic food. Additionally, CHASS supports community interventions to improve access to integrated care, treatment adherence, and health outcomes of PLHIV.
Key activities this quarter
During their TSVs to HFs, CHASS zonal teams continued to follow up and mentor HF workers in integrating all elements of the national nutrition rehabilitation plan into the care and treatment of PLHIV. Specifically, CHASS teams emphasized nutritional screening of all PLHIV, nutritional counseling, and prescription of nutrition supplements to boost the nutrition of malnourished adults and pediatric patients. To enhance nutrition assessment, CHASS trained HF workers in Ponta-Gea, Munhava, Mucurrungo, Mascaranhas, Nhaconjo, and Provincial Hospital of Beira. The training focused on how to perform and interpret anthropometrics measures.
Major activities planned for next quarter
Through TSVs, continue strengthening the technical capacity of health providers to implement the nutrition rehabilitation program by integrating it into the care and treatment of PLHIV in accordance with the directives issued by MISAU.
Continue facilitating CHASS pharmacy staff to support HFs in stock management of nutritional supplements, including forecasting, quantification, and preparation of utilization reports.
Work with FANTA to train more health care providers in nutrition best practices as well as provide necessary tools and resources. This activity will focus on the 16 priority sites in provincial capitals.
Conduct a nutrition assessment at 16 priorities sites using “Quality Standards for Measuring Performance of Nutrition Rehabilitation Program Services.”
Support CBOs to continue doing nutrition education using available IEC materials and demonstrations to promote good nutrition practices at the community level.
Health System Strengthening
In FY17, CHASS-supported HSS activities are focused on strengthening systems to improve access to and quality of services at the HF level, so as to enhance HIV case detection, increase the number of PLHIV on treatment, and improve retention. Activities implemented in the quarter aimed to improve the efficiency of HIV services at large-volume, urban scale-up sites by reducing waiting times, streamlining patient flow across the continuum of care, and improving provider-client relationships. In a site where targeted activities were piloted, the team observed a 50 percent reduction in waiting times and improvements in HF organization and cleanliness. This initiative will be scaled up in more sites as part of efforts to improve the quality of care and retention.
43 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
The HSS sub-sections below outline the key HSS accomplishments at provincial, district, and site levels in the areas of governance and leadership, finance, human resources for health (HRH), supplies and logistics, and public-private partnerships (PPPs).
Governance and leadership at DPS, SDMAS, and HF levels
During the quarter, the project rolled out an HF-level HSS intervention package targeting high-volume, urban scale-up sites to improve efficiency in HIV service delivery. Prior to interventions, CHASS conducted 33 site assessments to identify opportunities for improvement. These culminated in QI action plans to address identified needs. The teams also worked with the HFs to map patient flow and the location of HIV service delivery points at seven sites, measuring patient waiting and consultation times at 13 sites, and evaluating client satisfaction at all HIV service delivery points at 12 sites. The results were then analyzed together with site staff to identify bottlenecks5 and high-risk areas for leakages in the treatment cascade, identify areas of exposure to infectious diseases to non-infected patients (i.e., in the TB ward), and assess whether the patent flow is aligned with the latest MISAU standard operating procedures. Data from respondents were analyzed to identify potential solutions for increasing user satisfaction and adherence to HIV services.6 Sites then developed and implemented QI action plans such as reorganizing the location of key HIV services to simplify patient flow, adjusting the location of services to reduce the distance between sectors, and sometimes isolating the TB ward to ensure greater separation between PLHIV and TB patients. CHASS also supported 10 HFs to reduce waiting times by conducting manual HIV patient file reviews and improving archival organization to ensure faster patient file retrieval and to fast track patients eligible for key services (e.g., rapid flow, lab tests).
The impact of this HF-level systems strengthening package will be measured quarterly. Preliminary findings from Tete ‘rovince’s CS Nº 2, where this intervention package was first implemented in October 2016, showed promising results after three months, with average ART consultation waiting times dropping 59 percent, from 2 hours and 22 minutes (n=11) to 58 minutes (n=14), and average consultation times increasing 33 percent from 12 minutes to 16 minutes. Similar results were found in CCR, with average consultation waiting times dropping 49 percent, from 59 minutes (n=5) to 30 minutes (n=12), and average consultation times increasing 31 percent, from 9 minutes to 13 minutes.
To improve service delivery conditions at the HF level, CHASS began processes for minor repairs and replacement of essential furniture and supplies. The project completed its assessment of the bills of quantities required to inform tender documents to contract companies that can implement this work. Concomitantly, CHASS zonal teams worked with HF managers to draft work plans for equipment and repair needs at 147 HFs (Sofala: 63; Manica: 32; Tete: 42; Niassa: 10) in scale-up districts, which will be informed by the above-mentioned bills of quantities, and funded via the site-level funds available within the each DPS’s CHASS sub-agreement. The project also completed some HF maintenance during the quarter, namely the repair of the Eduardo Mondlane public bathrooms, as well as the installation of HTC privacy testing booths and dividing walls for pharmacy drug pick-up privacy in Manica province.
5 Common bottlenecks identified included high-volume days during the week when patients tend to visit the HFs, particularly on Mondays and Fridays; long waiting times to find HIV-positive patient files; and a low percentage of eligible patients on the rapid flow (fluxo rapido). 6 Common concerns included long waiting times, inadequate patient triage, lack of privacy, poor site hygiene/cleanliness, inadequate signage of services, poor ventilation of consultation rooms, common stock-outs of certain medications, and lack of functional bathrooms. Common areas of satisfaction included the bedside manner of health care workers, clarity of clinical instructions and explanations, and efficiency of the one-stop model with all services in one clinical visit. 44 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Logistics supply chain management
The CHASS project continued to support the government of Mozambique at different levels to ensure that HFs have essential medical products (e.g., drugs, vaccines, test kits, reagents) for HIV/AIDS management. During the quarter, CHASS focused its support on working with the Sofala and Manica DPSs, as well as the Clinton Foundation, to design and publish requests for proposals from third party contractors to assume responsibility of the transportation of all health commodities from the provincial level to the district level. By the end of the quarter, the two provinces were in the process of selecting the most competitive contractors to manage the DPM-to-DDM supply chain network.
CHASS also continued to update existing supply chain management route maps and schedules to incorporate new ART sites in seven scale-up districts in Tete and Niassa provinces. The project also implemented the 5S QI Program in Changara district’s DDM to improve inventory management and access to essential commodities and medications. Logistics support was also focused at Test and Start sites with increased inventory monitoring, where the project supported sites when necessary to reduce the risk of stock-outs and expiration of commodities by redistributing them among HFs.
Financial management
The project strengthens financial management by using the CHASS provincial and district sub- agreements to track and improve DPS and SDSMAS adherence to the government of Mozambique’s financial management procedures in collaboration with the government compliance department. During this quarter, CHASS TA teams supported sites to access districts and HFs to strategically plan and efficiently budget their work plans to access project sub-agreement funds. At the district level, this involved working with district supervisors to review and report quarterly performance, and to make realistic plans for the next quarter. At HFs, this involved supporting 147 sites (Sofala: 63; Manica: 32; Tete: 42; Niassa: 10) to assess their needs and fill out their work plans accordingly to access the available provincial sub-agreement funds dedicated to the HF level.
Human resources for health
During the period under review, the project focused its HRH support on working with district HRH managers to analyze GIS maps identifying HFs with staffing gaps in terms of the ratio of providers to HIV-positive patients and the percent of staff with HIV competencies. CHASS also supported the development of action plans that then guided in-service training and plans for allocating new staff graduating from pre-service training institutes. Overall, by the end of the quarter, 120 staff received in- service trainings at the district level with CHASS support. An additional 391 staff received CHASS- supported in-service trainings at provincial and community levels. Annex 5 outlines the specific themes and number trained in each province by funding mechanism, all of which were reported in MISAU’s in- service training information system and USAID’s TraiNet with support from CHASS.
The project also presented a proposal to implement an incentives program that rewards the best performing SDSMAS, district manager, HF, HF sector, and health care worker. With the exception of Sofala, all DPSs approved the proposal in December, and local CHASS field offices are working with their respective DPSs to procure the symbolic prizes that will be rewarded based on performance. In addition, CHASS provided routine TA to the HRH managers at district and provincial levels during the quarter. This involved working with SDSMAS HRH managers from four districts to provide TA to support 45 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
implementation of the QI action plans that resulted from the second round of system capacity builder approach (SCBA) HSS assessments in the July to September quarter. The project also supported large- volume sites to formally document terms of reference for staff providing HIV/AIDS care and treatment services in order to ensure that each health care worker knows his or her roles and responsibilities. In terms of pre-service training, CHASS continues to support 185 students across five courses in Sofala, Manica, and Tete, including 61 medical technicians (35 in ICS Beira and 26 in ICS Chimoio), 96 MCH nurses (35 in ICS Beira, 29 in ICS Chimoio, and 32 in ICS Tete), and 28 laboratory technicians (ICS Tete). All these students are expected to graduate before the end of the CHASS project in June 2018.
Public private partnerships
CHASS is using PPPs to contribute to greater impact and sustainability through private-sector engagement in the delivery of HIV care and treatment services. Following the signing of the PPP, the National HIV Program requested an additional memorandum of understanding between CHASS and MISAU. During the period under review, CHASS staff met with MISAU leadership to respond to their questions and concerns. By the end of the quarter, MISAU’s national director for the directorate of public health gave verbal approval, but asked the project to hold off on initiating HIV/AIDS care and treatment support to the Companhia de Vanduzi and Sena Sugar Company until written approval was signed by the minister. However, MISAU did give authorization to begin implementing the PPP at CFM, as it is a parastatal company.
Key HSS activities for the next quarter
In Q2 of FY17, CHASS will: Continue to roll out the new HF-level systems strengthening intervention package targeting high- volume, urban scale-up sites. Implement round 3 of the district health system assessments to strengthen SDSMAS management capacity for improved service delivery. Continue updating and supporting implementation of each scale-up district’s in-service training plans based on data analysis of GIS maps illustrating key HRH ratios and staff competencies. Support DPSs to implement a new incentives program to reward the best performing SDSMAS, HF, and health care worker as a part of the project’s strategy to increase HRH retention and encourage strong performance toward achieving the set targets.
Quality Improvement
CHASS QI efforts aim to define approaches to ensure that HFs meet national standards for HIV care and treatment. This entails frequent measurement of the standards related to HIV service delivery. During TSVs, CHASS zonal teams review practices against standards of care. Findings serve as the basis to develop action plans for improvement. CHASS’s goal is to achieve performance greater than 90 percent in all QI indicators. Apart from monitoring adherence to clinical care standards, CHASS pursues QI by promoting humanization of the services at the HF level. The two approaches are consistent with national QI guidelines.
During the quarter, CHASS participated in MISAU-led national HIV/AIDS QI initiatives including 1) implementation of action plans for the first national QI cycle and 2) experience exchange. All HFs 46 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
implementing the national QI approach came together in a meeting to share their experiences and support each other. CHASS supported participants from the four provinces. At the national level, the CHASS senior technical officer participated in MISAU-led QI activities including 1) developing templates, terms of reference, and guidance for the experience-exchange meetings; 2) defining indicators for the second national QI cycle; and 3) developing the qualitative and quantitative QI platforms.
In terms of CHASS-specific QI activities during the quarter, the CHASS quality assurance team focused on 1) training CHASS technical teams in the four provinces on the FHI 360 TA approach; 2) implementing various plan-do-study-act (PDSA) cycles to address gaps observed by external (FHI 360 global team) TA providers or identified by the CHASS teams during performance measurement; 3) supporting provinces to improve performance (focusing this quarter on Manica in a bid to increase the number of PLHIV initiating ART and improve retention); and 4) viral load training. This was facilitated by the Sothern African HIV Clinicians Society (SAHIVSoc) and had participation from the National HIV/AIDS Program and ART committee members.
One specific example of the PDSA cycle approach was their use to address sub-optimal levels of HIV testing in facilities in Chimoio where on average, less than 4 percent of patients attending were tested for HIV. With an aim of increasing coverage from 2 to 40 percent at ten high-volume facilities, CHASS trained health facility staff through a 1-day workshop on the objective and approaches to be used to monitor staff performance and provide daily feedback. Beginning on December 12th, they began revising their approaches and tracking performance on a daily basis. In the seven days remaining in the quarter, performance was tracked at these sites and dramatic improvements were seen (Figure 19). Providers rapidly improved their performance once they were aware they were not performing as expected and had clear targets for testing. During this cycle, the activities focused on adult and pediatric triage units; in Q2 this has been expanded to emergency services and hospital wards.
Figure 19. Improvements in testing coverage at ten high-volume sites in Chimoio during a PDSA cycle 60%
50% 45% 49% 40% 39% 33% 29% 30% 32% 27% 20%
10%
0% 2% Baseline 12 DEZ 13 DEZ 14 DEZ 15 DEZ 16 DEZ 19 DEZ 20 DEZ
Quality improvement-related activities for next quarter
Roll out the training package for the second cycle of the MISAU-led QI approach. Conduct the final assessment for the first national QI cycle and a baseline assessment for the second cycle. 47 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Continue to support CHASS provinces in implementing PDSA cycles to improve performance in priority indicators and the use of cascade analysis to identify gaps and opportunities for PDSA cycles.
IR 2: Strengthen community-based HIV services – access, quality, and retention Activities implemented under IR 2 of the CHASS project aim to provide high-quality, coordinated, community-based HIV services to enhance PLHIV access, retention, and adherence to ART. Ensuring access to quality services and retention of clients is done through various combined strategies including community mobilization, C-HTC, and community-based care to enhance treatment adherence and retention as well as linkages with HFs. Although community-level activities have been in operation since the beginning of the project, approaches, standard operating procedures, and tools from previous projects have had to be modified to respond to current project priorities. Dissemination and implementation of these tools and guidance documents was complete in Q4 of FY16, but changes in monitoring requirements required modifications of collection tools and reporting systems as well as re-training all CBO and community staff in this quarter.
Community services to support retention CHASS continued to support a package of community services that includes early supportive visits to newly diagnosed HIV-positive patients (within 15 days) by activistas and continued visits in particular during the first three to six months of ART initiation. The content of the visits includes reinforcing ART literacy, adherence counseling, disclosure, and psychosocial support and positive prevention. To ensure that this was effectively done during the quarter, all CBO staff received integrated training including on documenting referrals and counter-referrals; facilitating enrollment of ART clients in peer support groups; encouraging GAACs within these groups; and coordinating engagement with community health committees, other community health workers, and facility-based co-management committees. Strengthening technical capacity of CBOs: In order to improve the quality of community activities, CHASS provided resources to each CBO to hire technical supervisors who will guide implementation of community activities with oversight from CHASS staff. Additionally, CHASS provincial teams began implementing an integrated supervision approach in which CHASS community staff as well as CBO supervisors carry out joint visits to each priority site, at least quarterly, within the zonal team framework. Results are discussed within the team, which includes clinical, monitoring and evaluation (M&E), and program management staff, in order to establish a common action plan. DPS and SDSMAS community staff are also included. During integrated visits, CBO supervision staff provide TA in the sites they are responsible for. CHASS also mentored CBOs on how to be more creative and flexible in solving problems, such as by adopting more flexible working hours. In Manica, activistas were having trouble finding defaulters (especially males) during their usual working hours (8am to 1pm), but they found that if they conducted searches in the afternoon or on Saturdays, they often had more success. In Tete, during the rainy season PLHIV often re-locate to work on farms, and the return rate from defaulter tracing is very low. Discussions were held with the SDMAS in Changara to work closely with community leaders to more effectively reach defaulters. Support groups Village Savings and Loan Clubs: Promotion of PLHIV participation/enrollment in GAACs and support groups such as mother-to-mother, men-to-men, adolescent, caregiver, and general groups 48 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
continued, albeit with challenges of continuity and cohesiveness. To mitigate this, CHASS continued to encourage PLHIV membership in village savings and loan clubs, creating more group cohesion. In Sofala, CHASS facilitated the recruitment of appropriate candidates in HF waiting areas as well as creating synergies with Dreams and Challenge TB. At the end of the quarter, the proportion of village savings and loan club members who were PLHIV had increased to 43 percent from an estimated 20 to 30 percent in previous quarters.
Household visits: Household visits are especially important in “Test and Start” sites, where many people are initiating ART when they feel well, putting them at higher risk of defaulting. The 16 priority sites were the focus of TA to support the implementation and recording of these visits. For the first time this quarter, CHASS community partners collected data on the number of household visits made. More than 6,500 visits were reported to close to 6,000 patients. While this is just over one quarter of all new patients this quarter, this is likely due to the fact that household visits were not being tracked until now. Furthermore, anecdotal evidence suggests that even where it is being implemented, not all new patients received visits. Health Facility staff found that not all patients required a visit. Some patients refused to be visited for reasons of confidentiality and others were at low risk of defaulting. Furthermore, data on household visits were reported by CBOs associated with 107 different health facilities of the more than 380 CHASS supports. Among facilities covered, 59 facilities had data reported in all three months whereas 20 facilities had data reported in two months of the quarter and 28 only in one month. This variable reporting is due in part to this being the first quarter in which these data were collected and the tools were not introduced simultaneously in all locations. Among the visits that were reported, thirty eight percent of visits were reported to be initial visits and 62 percent repeat visits. Among those who were visited, 37 percent were male and 63 percent female and 28 percent were children and 72 percent adults.
Intensive activities to promote retention in Manica
Because of low retention rates in the previous quarter, this quarter CHASS made intensified facility- and community-based efforts to improve retention in Manica. In the community area, focus was put on: Promoting and facilitating pre-ART home visits whereby patients who tested HIV-positive and were at risk of not returning within 15 days to initiate treatment were visited at home. Early and intensive home visits (or calls) in the first three months after initiating treatment, starting in the first 48 hours for those at higher risk for defaulting. This is the period when side effects begin to occur; thus, early visits are considered crucial to treatment success. Activistas used these visits as opportunities to verify whether the PLHIV had disclosed their status to their sexual partner(s) and whether their partners had been tested. Home visits also provided an opportunity to reach and retain more men.
In Sofala, an activist making a home visit in Nhangau arrived at a crucial moment in the life of a couple who had both started ART the week before. They were both experiencing side effects and had decided to stop taking their medicine that day. The activista told them that some side effects are expected and advised them to go back to the Health Center to talk with the doctor rather than stopping. When doing a pill count the activist noticed that they had identical medicine containers that were not personalized, so they could not track their individual adherence. The activista resolved this by writing their initials on the bottles.
49 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Community counseling and testing
Intensive efforts continued to shift the community testing approach away from mass campaigns and a “family-centered” approach, to a more focused approach targeting the sexual partners of index clients, through sexual/social network testing, as well as their younger children. OVC and their parents are also key target groups, as are key populations, in coordination with LINKAGES. After testing, counselors continue to visit HIV-positive patients until they enter into care and treatment. Community lay counselors have all been trained and certified, but continue to need mentoring in the proper application of the index case approach.
The positivity rate continued to increase, although the proper application of the index case approach was still not entirely consistent, as shown by a more detailed analysis at district, HF, CBO, and individual counselor levels (see testing and counseling section for discussion of results).
CHASS-supported CBOs are implementing a system for setting targets and tracking performance of individual counselors, allowing CBOs to focus their capacity building efforts more efficiently on the individual counselors, where it might make the most difference. Continual TA is necessary so that all counselors can fill in the C-HTC forms, which they reportedly find difficult and complex.
Challenges
Changing data collection forms in the middle of the quarter presented a major challenge for CBOs because they had already produced the other forms in large quantities to avoid stock-outs. Also, the changes required altering the database as well as reporting templates. Forms had to be reproduced and distributed, and all personnel had to be trained in their use. Also, when indicators are changed in the middle of a reporting cycle, it is extremely time consuming to manually analyze data from the period. Further, time planned for TA must be diverted to re-training all staff in use of the forms. Even so, community personnel have trouble adapting to change and often confuse versions or misinterpret instructions, affecting data quality. Occasional RTK stock-outs were reported, and in most cases the problem involved inadequate stock management. As this was not the case in HFs, CBOs were advised to adopt practices for regularly recording and reporting RTK use and timely requisition of additional test kits to avoid stock-outs.
Major activities in the next quarter
CHASS will hire an mHealth senior technical officer next quarter, to move forward with community-level mHealth activities in priority sites in coordination with FHI 360’s Maputo and Vietnam LINKAGES activities and Dimagi, which has developed the CommCare application for U.S. Centers for Disease Control and Prevention (CDC) partners in Mozambique. The CommCare application will track home visits, searches, and testing activities including follow-through to care and treatment. We will also be instituting SMS reminders to patients either through CommCare or through OpenMRS.
50 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
IR 3: Strengthened referral/linkage systems between community and facility- based services
Effective systems for referrals and linkages between communities and HFs are essential for maximum ART initiation, retention, and adherence to treatment. Activities imlemented by the CHASS project under IR 3 aim to strengthem these systems. During the quarter, several interventions were implemented.
Facilitated linkages between community HTC and HF care and treatment
CHASS continued to support CBOs to ensure that community counselors facilitated linkage of HIV- positive individuals to care and treatment immediately after testing positive. Community counselors must visit consenting patients until they are linked to health services and continue to visit until they actually initiate treatment. Each province is developing registers for 1) HFs to follow up on index cases and their contacts and 2) community counselors to coordinate follow-up of positive patients through to care and treatment, the results of which will then be shared in order to establish best practices.
CHASS continued to facilitate deployment of a “circulating community case manager” (GCC circulante) in high-volume HFs to physically escort patients to the appropriate medical consult area. This strategy of using circulating community case managers was adopted because the other case managers are placed in fixed sites, and may find it difficult to leave if they are involved in health education sessions, checking patient charts or FILAs against defaulter lists, or preparing charts for the following day in sites using agendas.
During the quarter, CHASS used the PDSA tools to evaluate whether the circulating community case manager can make a significant contribution to strengthening linkages between diagnosis and treatment within the HF. The intervention showed impressive results as shown below.
PDSA intervention: Escorting HIV-positive patients from HTC sites to care and treatment sites in order to increase the proportion of HIV-positive patients inscribed in ART by improving linkages between diagnosis and HTC.
Table 7. Results from a PDSA cycle on engaging circulating case managers to improve ART initiation Province HF Baseline PDSA Results with Escort Tete C.S N˚2 51% 82% Manica C.S Eduardo Mondlane 66% 80% C.S Ponta Gêa 60% 78% Sofala CS Chingussura 60% 93% CS Chota 77% 100% CS Chamba 52% 95%
All sites that engaged circulating case managers showed a significantly higher proportion of patients enrolled in care and initiated on treatment as summarized in the table. Not all escorts were carried out by the circulating community case manager. Some patients were escorted by “fixed” community case managers assigned to a sector and clinicians. This PDSA exercise
51 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
was carried out by the zonal teams (led by the clinical team) as a QI approach to improving performance in terms of reducing leakage from diagnosis to ART initiation. In subsequent quarters, CHASS will emphasize the importance of this activity within their integrated TA visits, together with CBOs, to ensure that it is a priority. Provinces are also piloting internal referral forms (within HFs) to strengthen linkages.
Referrals
CHASS continued to promote and support referrals between communities and facilities and among various community services (intra-community referral) to ensure that PLHIV receive the full package of services that they require. This was done through training community staff and reinforced during TA visits. At the HF level, CHASS developed systems for tracking referrals from communities to health services as well as those patients received at facilities based on referrals. Data from this tracking will be analysed and used to close the gaps in referral systems.
In Q4, CBO staff in Niassa and Sofala who had not already received training in use of the national referral guides, were trained. In addition, CHASS worked with other FHI 360 projects to delineate roles and responsibilities of each project in a range of areas, including referrals. After the full introduction of COVida activities, these systems will be operationalized through provincial coordination forums (FHI 360 project teams). Moreover, CBOs began using new reporting tools and began entering their data into the project’s DHIS-2 database. These data may underreport referrals this quarter, as not all CBOs were using them for the full reporting period. However, they give an overview of the types of services that patients need and indicate the extent to which links between community and facility services are functioning.
Again this quarter, the most common reason for referral was busca consentida (13,053 patients referred, up from 6,340 in Q4). However referrals for MCH services (3,498) outpaced those for HTC (3,123) this quarter, a change from Q4. For all services except HTC, the number of referrals in Q1 was greater than in Q4. This quarter, 1,884 patients were referred by activistas for index case testing (this is in addition to patients referred from facilities to the community, discusssed below), an increase of more than 1,000 patients relative to last quarter. Relative to the number of people who were referred to facilities by activistas, a large number of patients came to the health facility for services, which is encouraging and means that activistas are communicating effectively and following up with patients who were referred. When calculated as a percentage, this ranged from a low of 82% for Busca Consentida to a high of over 100% for GBV and other HIV services. In fact, these percentages are a bit misleading as patients referred in one reporting period may return in a subsequent period. At the same time, this may be a data quality issue and will be reviewed as part of data quality visits to CBOs in Q2.
Table 8. Referrals reported for HF services—referrals made and patients received, FY17 Q1 Facility Services Other MCH HTC Index Case Busca TB GBV HIV # of sites reporting 118 117 22 145 73 104 31 Referrals made by CBOs to health facilities 3,838 4,028 506 13,053 1,445 1,797 127 Patients received at health facilities 3,505 3,247 NA 10,762 1,458 1,591 136
In terms of community services, almost 3,600 patients were referred to CHASS-supported community index case testing services from the 57 HFs reporting these data, more than double the number of patients referred last quarter. Likewise, 595 patients were referred to savings groups in the community
52 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
(from 22 sites reporting), 79 patients were referred to OVC services in the community (from seven sites reporting). Among those referred to community services, the majority were adults (78%) and more than half were females (56%). Given that women are more likley to be seen at health facilities, this suggests that the Community Care Managers in health facilities are prioritizing men for referrals. Community partners also reported that 464 patients had arrived at savings groups and 288 had arrived at support groups based on a referral. CHASS CBO activistas also referred patients to other FHI 360 projects. This quarter, 40 patients were refeferred to the Linkages project, 22 to CoVida, 138 to Challenge TB, and six to YouthPower. CHASS is working with other projects to track people who are referred in from other projects.
Defaulter tracing
CHASS continued to facilitate community staff (CBOs) to ensure that PLHIV who need services but are not coming to facilities are traced, counseled, encouraged, and enabled to get the available care services they need. Target groups included patients who have defaulted from or abandoned pre-ART or ART services, parents or guardians of infants whose PCR test results have arrived at the facility but who have not yet been informed (including positive results and rejected specimens that need to be re-collected), and patients who have been diagnosed as HIV-positive and are eligible for ART but have not yet started on ART. CHASS also supported searches for women who had taken post-exposure prophylaxis and who had not returned for their follow-up visits.
Accurate, complete, and up-to-date information is the basis of quality lists. In order to create accurate lists for searches, another series of activities were implemented aimed at intensively “cleaning” or updating lists for “Busca consentida.” This is important because when activistas go to houses to conduct physical searches for patients who have not actually defaulted, they are often met with hostility. Searches for patients who are currently adhering to their treatment regimens create mistrust of both HF and community-based activities. The list creation and defaulter tracing process included: EPTS: generating the list of defaulters and those who had abandoned treatment. Triangulating the list with various sources: reception, pharmacy (FILAs and prescriptions if FILAs are not updated), and medical consults. Generating the definitive list. Facilitating HF staff to carry out telephone searches (SMS and calls). Beginning this quarter, each ART site has funds for defaulter tracing and client referrals as part of funds channeled through the sub-agreement with the DPS. Initiating search within three days (telephone). Physical search to follow (three attempts, completed within two weeks). Assigning individual members of defaulter tracing team specific cases to search to enhance performance and accountability. As mentioned in IR 2 above, CBOs are implementing daily reporting in some high-volume sites for improved accountability and results. To help organize this activity, an individual daily, weekly, and monthly defaulter tracking tool was disseminated for their use. Illustrative of the benefits of individual performance tracking is the experience in Manica province at Health Center 7 April, where 152 patients in pre-ART were identified for searches. Through the implementation of three PDSA cycles, it was possible to return 93 percent (141/152) when there was a redistribution of patient lists to activistas who had good performance in the second cycle.
53 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Teams of community case managers worked evenings and weekends in Manica to ensure updated information. This effort along with HF clinical staff and CHASS zonal teams resulted in a 30 percent reduction of in the number of patients who actually required searches.
Another major challenge experienced in defaulter tracing was having accurate patient contact information. The ability of defaulter tracing teams, both at HF and CBO levels, to carry out phone or physical supportive visits as well as searches for defaulters depends on having accurate information. During the quarter, CHASS began testing initiatives that could help overcome the challenge. In Manica, corrective efforts implemented included: Verifying contact information (before testing), including confirming telephone numbers. Verifying contact information at each medical appointment. Escorting vulnerable/at-risk patients (i.e., gravely ill, mentally ill, those that live alone or in other challenging social situations) to homes (thereby verifying address as well as providing more intensive psychosocial support).
The importance of accurate contact information is illustrated by the experience of the Eduardo Mondlane Health Center in Manica. Of 153 patients identified as active in pre-ART, 58 patients who had a telephone contact listed were called and returned to the HF for inclusion in ART. Of the 95 without a telephone contact registered, only 15 (16 percent) were located by a home visit.
Additionally, to meet the increased targets for both testing and treatment, and to improve retention in Manica, CHASS began testing the use of teams of adherent PLHIV to carry out searches. Thirty PLHIV were trained and 12 remained active at the end of the quarter. These are semi-volunteers who are given a small stipend for transport, a snack, and communication. Because of the short period of time, we will evaluate the effectiveness of this approach next quarter.
Strategic Information
Electronic patient tracking system In Q1, retrospective data entry was completed at five new sites,7 and two of these sites were handed over to the relevant DPS while the remaining three are in the process of being handed over. Thus, CHASS now has a total of 30 sites reporting with the EPTS (Figure 19), and we are on track to meet the targets for 2017. In addition, retrospective data entry for Q1 eligible patients was completed at one new site,8 which allowed CHASS to report on newly enrolled patients using the EPTS. Retrospective data entry for other patients at Ponta Gea is currently under way, and the EPTS team expects to close this and proceed with the handover to the DPS by the second week of February.
7 CS Macate and HP Chimoio in Manica, HR Mutarara and CS Changara in Tete, and CS Mandimba in Niassa. 8 CS Ponta Gea in Sofala. 54 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Figure 20. Map of EPTS sites by year of hand over
In Sofala, the team started the implementation of the new server to cope with the growth of the EPTS database and prepare for the expansion to additional districts. We expect this process to be finalized during Q2, and the same process will then be replicated in Manica and Tete.
New computers have been distributed within the new EPTS sites in all four provinces. The procurement process for printers was completed, with the printers delivered in late December. These will be distributed in Q2 so that all EPTS sites will be fully equipped.
With regard to implementation challenges, the quality of the charts and registers at the HFs remains the key challenge. When information is missing, the data entry team is unable to enter the data and this slows down the entire process. However, this has been less of an issue at the new sites, where registers are more complete.
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In FY17, in addition to EPTS expansion, CHASS is focused on ensuring and improving the quality of the data in the system. One key step in this process is the posting of full-time data entry clerks to HFs after the handover is complete. These staff will ensure that EPTS databases are updated in a timely fashion, and will develop the capacity of HF staff for data entry and use through on-the-job training. CHASS aims to have clerks at all 16 priority sites by the end of Q2. As part of this effort, a new SOP for data quality and completeness assessment was developed, and the first evaluations will be conducted during the supervision visits planned for Q2. Supervision visits are planned to all provinces during Q2.
CHASS participated in the annual OpenMRS Implementers’ Conference, which took place from December 6 to 11 in Kampala, Uganda. The event provided an opportunity for the team to learn from different experiences and approaches being used both in Mozambique and in other countries. It was also important for the team to become aware of different tools being developed that will add value to our current OpenMRS implementation. Amid the set of tools presented, the team underlined three that may contribute to the improvement of data quality in the short term, namely 1) Biometric (fingerprint) for Patient Identification in OpenMRS, 2) Offline Data Collection Using Mobile Devices; and 3) SMS Messaging from OpenMRS. All these tools are currently under development, but both SMS Messaging and Biometric for Patient Identification appear close to be ready for testing. The team will maintain contact with the organizations that are at the forefront of these developments and arrange for pilots within our current OpenMRS sites once the tools are ready for testing. Offline Data Collection Using Mobile Devices is already in the testing phase, although several technical issues were raised that may take a while to sort out. Nonetheless, the team will maintain contact and follow up with the developments.
In addition to the CHASS implementation, in Q1 the CHASS EPTS team collaborated with the University of California at San Francisco (UCSF) team to test and debug the queries developed for monthly reporting. In addition to ensuring accurate reporting by CHASS, this is an important contribution to the national system.
Community data systems This quarter, CHASS continued to strengthen the community M&E system and made changes to ensure that the new MER indicators could be reported. A training was held for the community services team to review the new tools and processes and to introduce the DHIS-2 dashboard that CHASS has developed for community partners. The training took place in Manica in December, and 85 people were trained. The new CBO dashboard presents key indicators and graphs for each partner at the touch of a button and will be updated each quarter with the latest data. Provincial M&E teams provided support to the CBOs for reporting, but reporting was a challenge this quarter, particularly because of a change in forms mid-quarter necessitated by revisions to PEPFAR indicators. In Q2, CHASS will provide more intensive support and follow-up to the CBOs with visits by both the provincial M&E teams and the central M&E team.
Data use In 2017, CHASS will strengthen work on data use with both CHASS staff and health system staff at all levels from the HFs to the provincial teams. In November 2016, CHASS held a five-day workshop for CHASS M&E and technical staff from the central level and the provinces to review graphics currently used by the project and develop an improved approach to data visualization. Two technical advisors from headquarters led the workshop, which also introduced Power BI and ArcGIS online as tools that
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CHASS will pursue for data visualization in the coming month. CHASS issued a request for proposals for a consultant to work with the project to rapidly develop a PowerBI platform for use by the project; the consultancy will be awarded in late January with the aim of having a draft platform by the end of Q2.
Crosscutting activities
CHASS also participated in several initiatives, led by the U.S. government, around data. These included:
Piloting a tool for capturing more complete information on PICT, including denominators. CHASS piloted the tool prepared by CDC staff and shared the results as requested. We also did a comparative analysis of the data that were collected using this tool for a one-week window, and of the data that were collected by the project on an ongoing basis over the course of the year. The data already collected included the desired disaggregations but did not include the denominators (number of people seen in each service point). The comparison of these results highlighted the weaknesses of the approach being proposed by the CDC, which involved a very short-term sample (one week). For example, the results from the CDC pilot showed 40 percent positivity in Banco de Socorro, whereas our data from 49 sites over the course of the year9 showed a positivity rate of 8 percent and only 7/49 sites with positivity about 10 percent. We shared these results with USAID and the CDC but have had no response.
Working with eSaude and the CDC partners to implement new monthly reporting of new indicators at key, high-volume sites. The queries for these reports were developed by a team of partners, including CHASS, and the final queries were shared by UCSF. CHASS conducted a thorough review of the queries when they were released prior to the December reporting deadline and noted discrepancies between the results of the queries and our own analysis of the same data. These discrepancies were shared with USCF and resulted in revised queries that are now being used by all partners.
Revising CHASS systems to align with new MER indicators. With the revisions to the MER indicators shared in October, CHASS revised the data collection system (tools and processes) to respond to most of these changes. In some cases, the changes requested by OGAC are not feasible in the Mozambican context, particularly without creating a parallel data collection system. CHASS will continue to discuss these challenges with USAID and the U.S. government team.
PROJECT MANAGEMENT AND IMPLEMENTATION
Collaborative performance review meetings During the quarter, the CHASS management team organized two collaborative review meetings with stakeholders and partners. The meetings with stakeholders included participants from MISAU, DPSs, and USAID. The first meeting was conducted in Chidenguele on November 21-23, 2016. The purpose of the meeting was to review the performance of the project against FY16 targets and to identify gaps, challenges, and solutions to inform the FY17 annual plan. The meeting was also used to reinforce
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operational policies, systems, and procedures necessary for continued and consistent compliance to USAID/FHI 360 standards and regulations.
A second meeting was conducted with MISAU, DPSs, and USAID in Maputo on December 14-15, 2016. The meeting’s objective was to present and discuss the results of the first year of the CHASS project implementation, discuss sub-agreements management, and share experiences from implementing Test and Start. The meeting was also used to identify gaps and challenges encountered during the project implementation and strategies to improve communication between the project and government partners. During this meeting, participants discussed the CHASS approach to funding HFs offering ART services in order to improve work conditions for both health providers and patients. Participants welcomed the new approach and made suggestions for improving the processes.
Visit by the Office of the U.S. Global AIDS Coordinator (OGAC)
On December 14, Michael Ruffner, Deputy Coordinator of OGAC, accompanied by other senior officials from PEPFAR and USAID Mozambique, visited CHASS-supported sites in Beira City, Sofala province. Sites visited were Ponta Gea Health Center, where the main interest was PEPFAR support to the molecular laboratory, and Kugarissica CBO, where interest was in understanding linkages between facility and community-based HIV/AIDS care. During the visit to the CBO, community case managers and activistas explained their work, the challenges they face, and how they overcome them.
Sub-agreement management with DPSs The program team in all four provinces continued providing support to DPSs in developing work plans and budgets, requisitioning for funds, tracking expenditure, reviewing means of verifications for completed milestones related to fixed-price sub-contracts, and putting in place mechanisms for disbursing funds to address HF needs. In total, provincial teams held 10 meetings with the different DPSs (Niassa: 3; Tete: 3; Manica: 2; Sofala :2).
Table 9. Funds disbursed to DPSs Balance Y1 Q1 Y2 Province In-Kind Fixed price In-Kind Fixed Price Total Q I Q I Manica 21,680,149.00 10,634,085.00 1,363,367.80 212,000.00 33,889,601.80 Sofala 34,764,718.01 3,997,714.00 10,937,049.14 4,035,936.00 53,735,417.15 Tete 41,983,243.40 10,078,120.00 9,771,180.77 191,278.00 62,023,822.17 Niassa 14,747,516.65 10,244,865.37 569,216.41 132,872.00 25,694,470.43
T O T A L 113,175,627.06 34,954,784.37 22,640,814.12 4,572,086.00 175,343,311.55
Sub-agreement management with SDMASs
The program team extended sub-agreements with SDSMASs until the end of the project. This will enable continuous implementation of activities and minimize delays occasioned by developing annual sub- agreements. Incremental funding obligation amendments will be made if and when necessary. FY17 work plan processes and end-of-year festivities delayed implementation of activities this quarter. This
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delay caused less disbursement of funds during the first quarter of FY 17 project implementation, but this will improve in the second quarter.
Table 10. Funds disbursed to SDSMASs during Q1 FY 17 Period Q1 Province Total Q1 Manica 330,510.00 330,510.00 Niassa 132,872.00 132,872.00 Sofala 10,566,948.00 10,566,948.00 Tete 397,802.00 397,802.00 T O T A L 11,428,132.00 11,428,132.00
Sub-agreement management with CBOs
In all four provinces, joint meetings with the CBOs and DPSs were conducted in order to discuss FY16 implementation activities, results, and challenges. The program team in collaboration with the community linkages team worked together with the support of the M&E team to develop clear tools and templates for quarterly progress reporting as well as achieving FY17 targets. CBO sub-agreements were modified in order to cover all needs identified in FY16, including human resources and IEC materials. In order to address the gap in human resources needed to reach targets, the number of counselors, activistas, and case managers paid by each CBO were increased, as was the amount of funds disbursed to the CBOs in Q1 of FY17.
Table 11. Funds disbursed to CBOs Province FY 17 Total Q1 Manica 3,884,498 3,884,498 Niassa 3,430,032 3,430,032 Sofala 33,384,598 33,384,598 Tete 2,910,064 2,910,064 T O T A L 43,609,193 43,609,193.14
Security and site accessibility
Although RENAMO and the Government of Mozambique agreed on a ceasefire toward the end of the quarter that has substantially improved the security situation, insecurity was a challenge in Sofala and Manica at the beginning of the quarter. Consequently, although CHASS teams were able to access some otherwise inaccessible sites in six districts in Manica and nine districts in Sofala for routine TSVs and data collection, they had difficulties reaching others. The affected districts in Manica were Machaze, Mossourize, Guro, Tambara, Macossa, and Barue. Those in Sofala were Caia, Marromeu, Gorongoza, Maringue, Chibabava, Machanga, Muanza, Chemba, and Cheringoma.
Overall, 282 of 388 (73 percent) of CHASS-supported sites were visited for data collection, which is a key measure of accessibility given that not all sites are required to have a TA visit during the quarter. It
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should be noted that accessibility may have varied over the quarter as the political situation changed, enabling data collection at the end of the quarter, although no TA visits were possible. Coverage varied by province and level of site support (Table 13). Whereas 100 percent of 10 CHASS-supported DSD sites in Niassa were visited, only 61 percent of the 66 such sites in Manica were visited; 77 percent of 60 DSD sites in Sofala and 95 percent of 39 DSD sites in Tete were also visited. Overall, coverage of the 175 DSD sites was 76 percent, while that for 46 TA sites was 70 percent.
This quarter, heavy rains during the period of data collection affected data collection at four sites in Tete. Roads were closed due to flooding.
Figure 21. Site accessibility by support type, FY17 Q1
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Table 12. Coverage of sites for data collection by province and support type, FY17 Q1 Support type Sim Total Not % visited CHASS DSD 133 175 42 76% TA 32 46 14 70% Other 117 167 50 70% ALL 282 388 106 73%
Manica DSD 40 66 26 61% TA 0 3 3 0% Other 13 29 16 45% ALL 53 98 45 54% Niassa DSD 10 10 0 100% TA 12 12 0 100% Other 61 61 0 100% ALL 83 83 0 100% Sofala DSD 46 60 14 77% TA 0 11 11 0% Other 6 37 31 16% ALL 52 108 56 48% Tete DSD 37 39 2 95% TA 20 20 0 100% Other 37 40 3 93% ALL 94 99 5 95%
MAJOR PRIORITIES/ACTIVITIES PLANNED FOR NEXT QUARTER
Continue supporting phase 1 T&S sites and ensure compliance with national guidelines. These sites will receive more TA (at least once a month) and monitoring to ensure success. Complete training of additional staff (lay counselors, MCH nurses, psychologists, activistas, and CCMs) to address HRH gaps and improve psychosocial support and referral services in the high- volume sites and communities to improve retention. Despite improvements in retention, further work is needed to meet the target of 76-percent retention on ART. Additional and fairly trained personnel will help in post-test counseling, adherence support, contract tracing of defaulters, and patient literacy. Continue supporting implementation of MISAU’s three-month ARV drug refills for stable patients in provincial hospitals so as to enhance adherence and retention. CHASS will work with the DPM and HFs to ensure that the HFs and personnel are prepared in terms of needs quantification, monitoring of stock levels, reporting, and record keeping. Additionally, we will continue to monitor the return of the enrolled patients for the subsequent three-month refill appointments. Continue rolling out the new HSS HF package of interventions targeting sites burdened with long waiting times. These include using a PDSA approach to measure patient flow and waiting/consultation times to identify and address bottlenecks by changing key processes in line with MISAU standards; implementing appointment registers to reduce bottlenecks; reorganizing patient file archives to ensure rapid access to client information; and screening individual files to ensure proper targeting of those patients eligible for ART and reduced site visits (fluxo rapido), and those in need of additional diagnostic exams (e.g., missing CD4 or viral load). Continue mentoring HF staff and CBOs on how to intensify measures to improve focus on the index case approach to community counseling and testing at HF, CBO, and individual counselor levels. 61 FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org
Support and monitor roll out of viral load implementation in all four provinces. Continue expanding EPTS implementation and achieve Q2 FY 17 expansion targets. Continue supporting CHASS provinces implementing PDSA cycles to improve CHASS performance and the use of cascade analysis to identify gaps and opportunities for PDSA cycles. Implement the HIV provider recognition program to reward and incentivize the highest-quality health system management and HIV service delivery. Strengthen implementation of presumptive diagnosis of HIV-exposed children in high-risk consultations so as to enhance prompt initiation of ART among HIV-positive children. Begin renovations and improving space for confidential counseling in the 16 priority sites
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ANNEXES
Annex 1. Sites in need of particular attention a) Sites with high positivity in PICT (>15%) in at least four quarters to date
# tested % Positive Q1 Q2 Q3 Q4 Q1 Q1 Q2 Q3 Q4 Q1 Manica / Cidade De Chimoio / Hospital Provincial de Chimoio HP 1177 2968 1513 933 838 28% 24% 24% 23% 26% Niassa / Mandimba / Mandimba CS II 532 529 551 481 295 27% 20% 25% 14% 23% Niassa / Marrupa / Marrupa CS II 78 355 400 358 207 17% 17% 20% 18% 17% Niassa / Mecanhelas / Caronga PS 16 31 26 44 72 44% 39% 12% 23% 25% Niassa / Sanga / Nassanhenje CS II (Sanga, Niassa) 46 43 48 40 53 15% 28% 21% 20% 25% Sofala / Buzi / Bura CS III 43 129 89 29 13 33% 19% 17% 41% 38% Sofala / Cidade Da Beira / Cerâmica CS III 22 265 103 181 233 18% 13% 41% 25% 18% Sofala / Cidade Da Beira / Manga Mascarenha CS III 884 1401 495 306 895 17% 9% 26% 23% 16% Sofala / Dondo / Dondo Sede CS I 96 3179 4652 2953 763 21% 12% 20% 25% 23% Sofala / Dondo / Igreja Baptista CS 523 120 159 97 141 7% 50% 40% 32% 35% Sofala / Dondo / Luzalite PS 4823 80 62 68 27 13% 49% 56% 46% 19% Sofala / Dondo / Maxarote PS 80 217 160 113 96 48% 31% 16% 12% 17% Sofala / Nhamatanda / Tica PS 12 271 418 128 201 17% 20% 12% 54% 18%
b) Low positivity sites in ATS (<5% positive)
# tested % Positive Q1 Q2 Q3 Q4 Q1 Q1 Q2 Q3 Q4 Q1 Tete / Changara / Centro de Saude de Boroma 11 164 57 59 29 7% 5% 3% 4% 0% Tete / Changara / Matambo © PS 34 37 38 12 6 5% 6% 5% 2% 0% Tete / Zumbu / Zumbo CS I 53 185 133 159 187 0% 0% 7% 6% 2% Tete / Chiuta / M'Vudzi Ponte 27 94 83 55 55 9% 29% 23% 22% 2% Tete / Mutarara / Inhangoma CS III 78 265 49 241 51 18% 19% 16% 13% 2% Manica / Guro / Mungari CS III 214 24 113 158 335 4% 4% 2% 0% 2% Niassa / Sanga / 7 de Setembro CS II 167 106 210 49 549 5% 5% 8% 2% 2% Tete / Tsangano / Centro de Saude de Fonte 175 218 164 Boa 15% 30% 18% 13% 2%
Niassa / Cidade De Lichinga / Lulimire PS 225 3% Sofala / Chibabava / Chibabava Sede CS II 123 72 60 77 65 7% 10% 15% 5% 3% Sofala / Machanga / Machanga (Sede) CS II 37 46 88 69 777 16% 15% 19% 7% 3% Tete / Chiuta / Manje 117 369 327 320 340 22% 23% 20% 17% 4% Niassa / Lichinga / Chimbonila CS 20 18 10 18 137 5% 17% 30% 22% 4%
Niassa / Majune / Malanga PS 158 4% Manica / Macossa / Macossa - Sede CS II 126 99 120 164 179 6% 7% 10% 7% 4% Tete / Angonia / Mpenha CS III 280 364 233 119 273 10% 7% 6% 0% 4% Tete / Changara / Cachembe PS 76 59 89 234 166 11% 19% 23% 14% 4% Manica / Tambara / Nhacafula CS I 308 320 300 360 325 1% 3% 4% 4% 4% Tete / Angonia / Dómue CS I 160 479 320 600 545 7% 10% 12% 6% 4% Manica / Gondola / Inchope CS III 360 380 1101 828 2186 18% 26% 8% 9% 5%
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c) High-positivity sites in ATS (>15% positive) in multiple quarters, life of project
# tested % Positive
Q1 Q2 Q3 Q4 Q1 Q1 Q2 Q3 Q4 Q1 Manica / Cidade De Chimoio / 1º Maio CS II 1300 1300 1160 1087 764 28% 31% 26% 21% 22% Manica / Cidade De Chimoio / 7 de Abril 818 1000 904 779 1135 27% 26% 23% 23% 16% Manica / Cidade De Chimoio / Chissui CSURB 318 339 346 333 341 26% 37% 28% 25% 25% Manica / Cidade De Chimoio / Eduardo Mondlane 1340 1388 1274 1240 1149 CSURB 24% 23% 24% 20% 17% Manica / Cidade De Chimoio / Nhamaonha CS II 507 553 412 476 293 35% 33% 33% 25% 27% Manica / Gondola / Macate CS III 97 109 26 17 74 18% 24% 27% 29% 27% Manica / Gondola / Matsinho CS III 64 48 141 74 123 56% 19% 22% 19% 19% Niassa / Cidade De Lichinga / Chiuaula PS 120 181 192 159 218 18% 18% 21% 19% 25% Niassa / Cidade De Lichinga / Lichinga Yes CSURB 360 364 267 246 193 19% 23% 24% 19% 18% Sofala / Cidade Da Beira / Manga Nhaconjo PS 594 726 481 751 502 26% 28% 24% 24% 31% Sofala / Cidade Da Beira / Ponta Gêa PS 395 482 471 707 599 22% 28% 37% 30% 34% Tete / Cidade De Tete / Cs Nº 4 - Bairro Muthemba 284 609 595 497 593 CSURB 23% 27% 22% 20% 19% Tete / Moatize / Moatize CS I 900 838 804 440 727 21% 19% 17% 18% 20% Manica / Cidade De Chimoio / Hospital Provincial de 920 1020 886 767 1174 Chimoio HP 18% 19% 18% 16% 13% Manica / Manica / Messica CS III 202 173 178 158 292 23% 25% 20% 13% 19% Niassa / Marrupa / Marrupa CS II 20 45 39 58 18 10% 27% 18% 22% 22% Sofala / Dondo / Dondo Sede CS I 568 494 933 1053 735 33% 20% 17% 19% 13% Tete / Chiuta / Manje 117 369 327 320 340 22% 23% 20% 17% 4% Tete / Cidade De Tete / Cs Nº 2 - Bairro Matundo 730 1316 1320 1325 1074 CSURB 26% 26% 14% 15% 23% Tete / Mutarara / Dôa CS III 27 7 127 163 342 20% 20% 25% 25% 6%
d) High-positivity sites in ANC (>20% positive), FY17 Q1
% com % positiva % estado para as MG positiva conhecido-- com uma de todos Site Total na entrada nova teste as MG Support registado mais testada (verde se (verde se (vermelha >5%; >5%; se >100% ou vermelha se vermelha <90%) <1) se <1) Sofala / Cidade Da Beira / Marrocanhe DSD 95 100% 20% 28% Sofala / Cidade Da Beira / Chota PS DSD 272 100% 20% 25% Sofala / Cidade Da Beira / Ponta Gêa PS DSD 938 100% 13% 25% Sofala / Cidade Da Beira / Manga Loforte DSD 343 100% 20% 24% Sofala / Cidade Da Beira / Manga Nhaconjo PS DSD 601 96% 15% 23% Sofala / Machanga / Beia-Peia Other 53 100% 9% 23% Sofala / Cidade Da Beira / Munhava CS III DSD 931 100% 12% 22% Sofala / Dondo / Mutua PS DSD 208 100% 16% 21% Sofala / Cidade Da Beira / Cerâmica CS III DSD 69 100% 11% 20% Sofala / Cidade Da Beira / Manga Mascarenha CS III DSD 373 100% 10% 20%
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e) HFs with ANC testing coverage of less than 90%, FY17 Q1
% com estado conhecido-- Site Total na entrada mais testada Support registado (vermelha se >100% ou <90%) Sofala / Caia / Deve PS Other 37 35% Niassa / Mecula / Lugenda PS Other 16 42% Sofala / Buzi / Ampara PS DSD 106 50% Niassa / Mecanhelas / Kumulike CS Other 164 56% Manica / Manica / Zonué-Tabaco CS III DSD 55 59% Sofala / Dondo / Chinamacondo PSA DSD 67 61% Sofala / Chemba / Chiramba PS Other 53 61% Sofala / Nhamatanda / Chirassicua CS DSD 94 61% Sofala / Caia / Caia CS I TA 66 62% Niassa / Mecanhelas / Centro de Saude de Chamba Other 231 64% Tete / Cidade De Tete / Cs Nº 3 - Bairro Manyanga CSURB DSD 555 65% Manica / Sussundenga / Matarara Other 96 66% Tete / Chifunde / Thequesse PS Other 166 68% Tete / Tsangano / N'Tengo Wambalane PS Other 210 68% Sofala / Cidade Da Beira / Macurungo PSA DSD 327 68% Tete / Changara / Ntemangau PS DSD 78 68% Tete / Mutarara / Jardim PS DSD 203 71% Niassa / Metarica / Namicunde PS Other 65 71% Sofala / Nhamatanda / Lamego CS III DSD 247 72% Tete / Chifunde / Nsadzo CS III TA 219 72% Tete / Mutarara / Sinjal PS DSD 214 72% Sofala / Chemba / Mulima PS Other 166 72% Sofala / Caia / Murraça CS III TA 139 73% Tete / Angonia / Catondo Other 316 73% Tete / Changara / Marara © CS III DSD 61 73% Tete / Chifunde / Vila Mualadzi PS Other 237 75% Niassa / Mecanhelas / Chissaua PS Other 327 77% Niassa / Mecanhelas / Entre-Lagos PS Other 284 77% Sofala / Maringue / Canxixe CS Other 155 78% Sofala / Dondo / Igreja Baptista CS DSD 91 78% Niassa / Mecanhelas / Chiúta PSA Other 135 80% Sofala / Dondo / Sengo CS DSD 36 80% Niassa / Mandimba / Lissiete PS Other 417 81% Tete / Zumbu / Zámbue CS III Other 216 82% Tete / Maravia / Posto de Saúde de Unkanha (Piripiri) Other 244 83% Sofala / Chibabava / Chibabava Sede CS II DSD 141 83% Niassa / Cuamba / Napacala PS DSD 150 83% Tete / Angonia / Seze CS Other 359 87% Tete / Mutarara / Inhangoma CS III DSD 453 87% Manica / Barue / Nhassacara CS III DSD 182 88% Tete / Angonia / Chimwala PS TA 232 90%
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f) HFs with <98% of TB patients aware of their HIV status
# # with % with registered Health Facility known known in the TB HIV status HIV status sector Manica / Sussundenga / Dombe CS II 17 15 88% Niassa / Mecula / Mecula CS III 12 11 92% Niassa / Ngauma / Massangulo CS II 27 25 93% Sofala / Caia / Caia CS I 86 81 94% Sofala / Cheringoma / Inhaminga HR 61 46 75% Tete / Macanga / Centro de Saude de Chidzilomondo 11 10 91% Tete / Mutarara / Chueza CS 4 3 75% Tete / Mutarara / Nhamayabwe CS 96 89 93%
g) TB service sites that are responsible for 70% of all coinfected patients
Note: highlighted sites were also key contributors in Q4
Manica Cidade De Chimoio Eduardo Mondlane CSURB Manica Cidade De Chimoio Nhamaonha CS II Manica Mossurize Espungabera CS I Manica Sussundenga Sussundenga Sede PSA Niassa Cidade De Lichinga Lichinga Yes CSURB Niassa Cuamba Cuamba CSURB Sofala Buzi Buzi Sede HR Sofala Cidade Da Beira Macurungo PSA Sofala Cidade Da Beira Manga Mascarenha CS III Sofala Cidade Da Beira Manga Nhaconjo PS Sofala Cidade Da Beira Munhava CS III Sofala Cidade Da Beira Ponta Gêa PS Sofala Dondo Dondo Sede CS I Sofala Marromeu Marromeu HR Sofala Nhamatanda Nhamatanda Sede HR Tete Cidade De Tete Cs Nº 3 - Bairro Manyanga CSURB Tete Cidade De Tete Cs Nº 4 - Bairro Muthemba CSURB Tete Moatize Moatize CS I Manica Machaze Chitobe CS I Sofala Chemba Chemba-Sede CS I Sofala Chibabava Muxungue CS III Sofala Marromeu Nensa PS Tete Changara Mazoé - Ponte CS III Tete Cidade De Tete Cs Nº 1 - Bairro Magaia CSURB Tete Moatize Zóbue CS II Tete Tsangano Banga
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h) Sites with large reductions in the number of newly enrolled patients between Q4 and Q1
# NI total Q4-Q1 % Q4-Q1 # UST Q1 Q2 Q3 Q4 Q1 Change Change Sofala / Cidade Da Beira / Chingussura CS III 346 134 344 362 -100% -362 Manica / Tambara / Nhacolo CS II 32 45 62 332 38 -89% -294 Manica / Machaze / Mavissisanga CS III 10 8 34 258 14 -95% -244 Manica / Tambara / Búzua PS 9 13 60 99 11 -89% -88 Manica / Barue / Catandica HR 166 103 350 157 90 -43% -67 Tete / Magoe / Centro de Saude de Magoe 60 72 64 69 8 -88% -61 Sofala / Buzi / Buzi Sede HR 94 104 143 163 103 -37% -60 Sofala / Marromeu / Marromeu HR 207 236 332 266 213 -20% -53 Tete / Macanga / Centro de Saude de Furancungo 43 38 66 66 16 -76% -50 Sofala / Gorongosa / Gorongosa Sede CS I 97 128 130 117 70 -40% -47 Tete / Mutarara / Dôa CS III 46 49 50 54 8 -85% -46
Annex 2. Facilities that benefited from CHASS commodity management technical support Province No. Of Health Facilities/ Departments Technicians Sofala 9 CS Ponta-Gêa, Chamba, Manga Loforte, Munhava, Macurungo, CS Dondo, Mutua, Mafambisse, HR Nhamatanda. Manica 12 DPM, Centros de Saúde Ed. Mondlane, 1° de Maio, Nhamaonha, Chissui, 7 de Abril, Vila Nova, CS Manica, CS Machipanda, CS Messica, Chitunga, Penhalonga Tete 48 DDM da Cidade, DDM de Chiuta, DDM de Moatize, DDM de Angónia, DDM de Mutarara, CS1, CS2 CS3, CS4 Niassa 13 CS Chiuauala, CS Namacula, CS Cidade de Lichinga, H R Cuamba, CS Cuamba, DDM Lago, CS Metangula
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Annex 3. Table illustrating the number of facilities receiving the support as listed above
Province
Manica Niassa Tete Sofala Focus of Technical Support No. No. No. No. No. No. No. No. DDM/ HF DDM/ HF DDM/ HF DDM/ HF DPM DPM DPM DPM Accuracy and timeliness of monthly 13 medicines and commodity (including test 3 2 11 kits) consumption reporting (MMIA) Updating of stock and inventory status of the 13 1 3 3 1 11 drugs and RTKs using existing tools The implementation and management of 5 2 1 4 3 SIMAM system at the DDM and DPM Distribution of Medicines through execution 3 1 3 16 of distribution plans
Annex 4. HFs supported in management of FILAs and LRDA in the four provinces Province District Health Facilities Tete Cidade de Tete CS 1, CS 2, CS 3, CS 4, CS Mpadue Moatize, CS 25 de Setembro, CS Moatize, CFM, Zóbue Angónia CS de Dómue,CS Lifidzi, CS Ulongue, CS de Ulongue Chiuta CS de Manje, CS Kaunda, CSMavudzi-Ponte Mutarara CS Nhamayabue, CS de Doa Sofala Beira CS Ponta-Gêa, CS Macurungo, CS Chamba, CS Munhava, CS Nhaconjo, CS Manga Loforte, CS Cerâmica, CS Matadouro Dondo CS Dondo, CS Mafambisse, CS Mutua Gorongosa CS Gorongosa Marromeu RH Marromeu Nhamatanda RH Nhamatanda Niassa Cuamba RH Cuamba, CS Cuamba Cidade de CS Cidade de Lichinga, HF de Namacula, HF Chiuaula Lichinga Lago CS Metangula
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Annex 5. CHASS in-service training achievements over the quarter, FY17 Q1 Sofala Manica Tete Niassa
Nº Training Theme Total
SAPIn-Kind Cost SADFixed SAPIn-Kind Cost SADFixed SAPIn-Kind Cost SADFixed SAPIn-Kind Cost SADFixed 1 ART clinical management 21 21 2 HIV care and treatment in key populations 48 18 30 3 Test and Start 60 60 4 EMTCT / Option B+ 18 18 5 TB/HIV pediatric clinical management 23 23 6 Youth Friendly Services providers (SAAJ) 32 32 7 Community finance strengthening 23 23 8 Male demand creation (Men2Men Groups) 20 20 9 Gender awareness raising training 30 30 10 Training in early infant diagnosis 23 23 11 Training for PIMA (Laboratory) 27 27 12 GBV case management 50 19 31 13 MCH manager supervision & management training 38 38 14 Viral load 98 58 40 TOTAL 511 167 81 153 39 71 0 0 0
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