PROJET INTEGRE DE VIH/SIDA AU CONGO

(PROVIC)

FINAL REPORT October 2009 through September 2014

Contract No. GHH-I-00-07-00061-00, Order No. 03

Submitted: December 30, 2014; Re-submitted: April 30, 2015; Re-submitted: July 15, 2015 (with Year 6 activities included as an Addendum)

Cover photos: Felix Masi Compilation of photos, DR Congo, November 2013

This publication was produced for review by the US Agency for International Development and was prepared by the PATH consortium.

The authors’ views expressed in this publication do not necessarily reflect the views of the US Agency for International Development or the US government. Table of contents

Acronyms and abbreviations ...... vi Executive summary ...... viii A. Introduction ...... 1 Background ...... 1 Project monitoring and evaluation system and framework ...... 2 Historical evolution of ProVIC: 2009–2014 ...... 4 Phase 1: (October 2009–July 2012)—Community-level prevention and impact mitigation with linkages to health facilities through the Champion Community approach ...... 4 Phase 2: (July 2012–March 2013)—Acceleration and expansion of prevention of mother-to-child transmission of HIV and expansion to include gender-based violence activities and Province Orientale ...... 5 Phase 3: (March 2013–September 2014)—Support for the PEPFAR Strategic Pivot to care and treatment and ProVIC expansion to 112 health facilities ...... 6 ProVIC’s operational presence ...... 6 B. Achievements ...... 8 Intermediate Result 1: HIV testing and counseling and prevention services expanded and improved in target areas ...... 8 Sub-IR 1.1: Communities’ ability to develop and implement prevention strategies strengthened ...... 8 Sub-IR 1.2: Community- and facility-based HIV testing and counseling services increased and enhanced ...... 13 Sub-IR 1.3: Prevention of mother-to-child transmission of HIV services improved ...... 20 Intermediate Result 2: Care, support, and treatment for people living with HIV/AIDS and orphans and vulnerable children improved in target areas ...... 32 Sub-IR 2.1: Care and support services strengthened ...... 32 Sub-IR 2.2: Care and support for orphans and vulnerable children strengthened ...... 42 Sub-IR 2.3: HIV treatment improved in target areas ...... 48 Intermediate Result 3: Strengthening of health systems supported ...... 51 Sub-IR 3.1: Capacity of provincial government health systems supported ...... 51 Sub-IR 3.2: Capacity of nongovernmental organization providers improved ...... 56 Sub-IR 3.3: Strategic information systems at the community and facility levels strengthened ...... 58 C. Lessons learned ...... 64 D. Challenges and proposed solutions ...... 68 Annex A. Monitoring and evaluation table ...... 71 Annex B. Environmental monitoring and mitigation activities ...... 72 Annex C. Maps ...... 73 Annex D. Submitted deliverables ...... 74 References ...... 120

iii Figures Figure 1. ProVIC cumulative results against cumulative targets, 2009–2014...... x Figure 2. ProVIC Results Framework...... 3 Figure 3. ProVIC phases and scale, FY2010–FY2014...... 4 Figure 4. DRC health system—the health care pyramid...... 6 Figure 5. Map of the DRC showing ProVIC’s presence and HIV prevalence by province...... 7 Figure 6. Number of ProVIC-supported CCs by fiscal year, October 2009–March 2014...... 8 Figure 7. Number and percentage of individuals by category reached with prevention messages, October 2009–September 2014...... 9 Figure 8. Number of individuals reached with prevention messages, October 2009–September 2014...... 10 Figure 9. MARPs reached with prevention interventions by fiscal year, October 2009–September 2014. 10 Figure 10. Number of males and females reached with prevention messages, October 2010– September 2014...... 11 Figure 11. Champion Community cycle...... 13 Figure 12a. Clients tested for HIV and seropositivity rates, October 2009–September 2011...... 14 Figure 12b. Clients tested for HIV and seropositivity rates in facility and community settings, October 2011–September 2014...... 15 Figure 13. Percentage of HTC by approach, before and after the Strategic Pivot...... 15 Figure 14. ProVIC-supported health facilities with high seropositivity rates by province, October 2011–September 2014...... 17 Figure 15. Pregnant women with known HIV status by fiscal year, October 2009–September 2014...... 21 Figure 16. Percentage of HIV-positive pregnant women who received ARVs by fiscal year, October 2009–September 2014...... 21 Figure 17. HIV testing and treatment outcomes for pregnant/breastfeeding women, October 2012– September 2014...... 22 Figure 18. Percentage of infants born to HIV-positive pregnant women provided with PMTCT services, October 2009–September 2014...... 23 Figure 19. Seropositivity of male partners, October 2012–September 2014...... 24 Figure 20. Male partners of HIV-positive pregnant women tested, October 2012–September 2013...... 30 Figure 21. Progress on HIV-exposed infant identification and treatment, October 2009– September 2014...... 31 Figure 22. Eligible adults and children provided with at least one care and support service by sex, October 2009–September 2014...... 34 Figure 23. PLWHA who received a minimum of one care service, October 2009–September 2014...... 34 Figure 24. HIV-positive adults and children who received at least one clinical service by sex, October 2009–September 2014...... 35 Figure 25. PLWHA who received CTX by fiscal year, October 2009–September 2014...... 35 Figure 26. Number of HIV-positive patients screened for TB, October 2011–September 2014...... 36 Figure 27. PLWHA who received a package of positive prevention services at community or facility settings, October 2010–September 2014...... 36

iv Figure 28. Participation of HIV-positive pregnant women in Kisangani in PMTCT interventions, March–October 2013...... 41 Figure 29. Key areas of care and support for OVC...... 42 Figure 30. Number of eligible children (younger than 18 years) provided with at least one care service by year, October 2009–March 2014...... 43 Figure 31. Number of OVC who received educational or vocational training support per year, October 2009–March 2014...... 43 Figure 32. Number of OVC who received educational support by sex and by educational level (primary, secondary, and vocational), October 2009–March 2014...... 44 Figure 33. Number of OVC referred for health services by year, October 2009–March 2014...... 44 Figure 34. Number of OVC who received psychosocial support by year, October 2009–March 2014. .... 45 Figure 35. Number of PLWHA who received CD4 testing, October 2011–September 2014...... 49 Figure 36. PLWHA initiated on HAART by year, October 2011–September 2014...... 49 Figure 37. Initiation of male partners on ART by province, October 2013–September 2014...... 50

Tables Table 1. Tools and assistance provided to the DRC MOH/PNLS...... xiv Table 2. Seropositivity of key and priority populations...... 16 Table 3. Numbers and percentages of male partners of pregnant/breastfeeding women tested and enrolled in treatment services, October 2012–September 2014...... 23 Table 4. Distribution of ProVIC-supported health facilities, October 2013–March 2014 ...... 24 Table 5. Completion of PBF contractual indicators at Kikimi Health Center, April 2013–April 2014...... 28 Table 6. Number of HIV-positive children on ART by sex...... 32 Table 7. ProVIC’s care and support activities...... 32 Table 8. Service providers trained on various topics, by provider category and fiscal year, October 2009–September 2014...... 52 Table 9. Transition of CCs following the end of ProVIC support, by province...... 56

v Acronyms and abbreviations

AIDS Acquired Immune Deficiency Syndrome ANC antenatal care ART antiretroviral therapy ARV antiretroviral medication C2C Child-to-Child CBO community-based organization CC Champion Community C-Change Communication for Change CCSC Champion Community Steering Committee CDC US Centers for Disease Control and Prevention CODESA community health committee COSA health center committee CSW commercial sex workers CTX cotrimoxazole DRC Democratic Republic of Congo EGPAF Elizabeth Glaser Pediatric AIDS Foundation EID early infant HIV diagnosis FANTA II Food and Nutrition Technical Assistance II Project FY Fiscal Year GBV gender-based violence Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria HAART highly active antiretroviral therapy HIV human immunodeficiency virus HIV/TB tuberculosis and HIV co-infection HTC HIV testing and counseling IDU injection drug user IGA income-generating activity IPC Initiative Privée de lute contre le VIH (Burkina Faso) IR Intermediate Result JADISIDA Jeunesse Active pour le Développement Intégré et lutte contre le VIH/SIDA (Active Youth for Integrated Development and the Fight Against HIV/AIDS) LIFT Livelihood and Food Security Technical Assistance M&E monitoring and evaluation MARP most at-risk population MER Monitoring and Evaluation Reporting MINAS Ministère des Affaires Sociales (Ministry of Social Affairs, Humanitarian Action and National Solidarity) MNCH maternal, newborn, and child health MOH Ministry of Health MSM men who have sex with men NACS nutrition assessment, counseling, and support NGO nongovernmental organization OVC orphans and vulnerable children PBF performance-based financing PCR polymerase chain reaction PEPFAR US President’s Emergency Plan for AIDS Relief PITC provider-initiated testing and counseling PLWHA people living with HIV/AIDS

vi PMEP Performance Monitoring and Evaluation Plan PMTCT prevention of mother-to-child transmission of HIV PNLS Program Nationale de Lutte Contre Le SIDA (National HIV/AIDS Program) PNMLS Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (National Multi-Sectorial Program for the Fight against AIDS) PNSA Programme National de Santé de l’Adolescent (National Adolescent Health Program) PNSR Programme National de Santé de la Reproduction (National Reproductive Health Program) ProVIC Projet Integré de VIH/SIDA au Congo (USAID flagship Integrated HIV/AIDS Project in the Democratic Republic of Congo) PSSP Progrès Santé Sans Prix (Progress and Health Without a Price) QA/QI quality assurance/quality improvement RDQA routine data quality assessment SCMS Supply Chain Management System SMS short message service STI sexually transmitted infection TB tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund USAID US Agency for International Development VSLA voluntary savings and loan association WHO World Health Organization

vii Executive summary

PATH and its consortium partners are pleased to submit this final report for the US Agency for International Development’s (USAID) flagship HIV/AIDS project in the Democratic Republic of Congo (DRC), Projet Integré de VIH/SIDA au Congo (ProVIC), No. GHH-I-00-07-00061, Task Order No. 03. In accordance with the US President’s Emergency Plan for AIDS Relief (PEPFAR) guidance and the DRC’s National Strategic Plan for HIV/AIDS, the US$49.4 million ProVIC project was designed to reduce the incidence and prevalence of HIV/AIDS and mitigate its impact on people living with HIV/AIDS (PLWHA) and their families in five provinces in the DRC: Kinshasa, Katanga, Orientale, Bas-Congo, and Sud Kivu. This report provides a summary of project activities and achievements from October 2009 through September 2014.

As USAID’s lead HIV/AIDS project in the DRC, ProVIC has established and sustained a leadership role in both high-quality service delivery and innovative technical support to government institutions at the national, provincial, and health zone levels by introducing and improving on key interventions, for example: • Mobilizing communities for HIV prevention via the Champion Community (CC) approach, self-help groups, and the Child-to-Child (C2C) model for psychosocial support of orphans and vulnerable children (OVC). • Improving HIV testing and counseling (HTC) approaches by introducing provider-initiated testing and counseling (PITC) in 112 health facilities, mobile outreach HIV testing for key populations of commercial sex workers (CSW) and men who have sex with men (MSM), and finger-prick testing technology. • Piloting and then rolling out at full scale, prevention of mother-to-child transmission of HIV (PMTCT) Options A and B+. • Introducing early infant HIV diagnosis (EID) and pediatric treatment. • Expanding availability of AIDS treatment to 112 PEPFAR-supported treatment sites, including improving clinical care through rapid, point-of-care CD4 testing and improved patient monitoring. • Introducing quality assurance/quality improvement initiatives through University Research Co., LLC’s “Improvement Collaboratives” approach, which ProVIC jointly adapted with the Ministry of Health (MOH) to the DRC context and then rolled out to 28 health facilities.

Historical evolution of ProVIC: 2009–2014

This report divides ProVIC into three distinct phases due to the many changes to its technical approach and scope over the past five years, reflecting advances in the field’s understanding of how to most effectively prevent and treat HIV and corresponding changes in PEPFAR’s DRC strategy.

Phase 1 (October 2009–July 2012): This phase emphasized HIV prevention and impact mitigation at the community level by mobilizing communities through the CC approach. It included broad community- based prevention among the general population as well as interventions to reach key populations. ProVIC prioritized building community-led prevention interventions with complementary community care and support services. Life-long treatment services were offered through Global Fund to Fight AIDS, Tuberculosis and Malaria-supported structures. Most at-risk populations (MARPs) of CSW, MSM, truck

viii drivers, miners, and fishermen were prioritized to receive prevention messages and mobile HTC and referrals.

Phase 2 (July 2012–March 2013): In this phase, ProVIC emphasized acceleration and expansion of PMTCT and expansion to include gender-based violence (GBV) activities and Province Orientale. Interventions targeting key populations continued. The project aligned activities with the DRC government’s Elimination de Transmission Mère Enfant du VIH (Plan for the Elimination of Mother-to- Child Transmission of HIV). Recognizing that 80% of deliveries in the DRC occur in health facilities, ProVIC’s facility-based work expanded from 16 to 44 health facilities in a “hub and spoke” model, in parallel with a shift in ProVIC’s community mobilization efforts from broad outreach through the CC approach to targeted PMTCT interventions for pregnant women and their households. Key populations of CSW and MSM remained a focus of ProVIC’s prevention, treatment, and support efforts, including targeted mobile HTC and referrals and adaptation of the CC model to key populations.

ProVIC expanded its services to Province Orientale in July

2012, opening and fully staffing a regional office in ProVIC/ACOSYF Photo: Kisangani in August 2012. Working closely with the Home-based care visit to a household in Bukavu Program Nationale de Lutte Contre Le SIDA (National Champion Community. HIV/AIDS Program) and coordinating with the Global Fund, ProVIC initiated PMTCT services in 12 health facilities in Kisangani before extending to six PMTCT sites in Bunia, a large town near the border with Uganda. ProVIC also established ten CCs, integrating GBV messages and referrals into the standard package of HIV/AIDS messages.

Phase 3 (March 2013–September 2014): Phase 3 prioritized support for PEPFAR’s Strategic Pivot to HIV care and treatment by expanding ProVIC’s reach to 112 health facilities. Access to treatment was emphasized through the opening of services at points of entry beyond PMTCT, including tuberculosis (TB), sexually transmitted infections, and at-risk inpatient care. In this phase, provision of PEPFAR- supplied antiretroviral therapy (ART) was increased to 112 health facilities. This approach reflected an increased emphasis on earlier treatment and treatment as prevention, based on scientific evidence that individuals on treatment are less likely to infect their partners.

ProVIC results: 2009–2014

Through ProVIC, PEPFAR has played a leadership role in the DRC’s response to the HIV/AIDS epidemic. ProVIC’s achievements across a range of technical areas are organized into three result areas as detailed by the ProVIC Results Framework (page 3). ProVIC’s overarching objective was to “reduce the incidence and prevalence of HIV/AIDS and mitigate its impact on PLWHA and their families.” Although the project was not supported or able to measure changes in incidence or prevalence, Figure 1 presents ProVIC’s five-year achievements against cumulative a priori annual targets. As noted in the figure, ProVIC met most cumulative targets as well as most annual targets, with 2012 being a challenge due to staffing changes, with outcomes for that year somewhat lower than expected.

ix ProVIC results: 2009–2014

Number of the targeted population reached with individual and/or smallNumber group-level of the preventivetargeted population interventions reached that withare based individual on evidence- and/or small group-leveland/or preventive meet theinterventions minimum that are based on evidence and/or meet the minimum standards required.

Number of people reached with individual, small group, or community-level intervention or service that explicitly addresses GBV Number of people reached with individual-, small group-, or (TOTAL) community-level interventions or services that explicitly address GBV and coercion. [TOTAL] Figure 1. ProVIC cumulative results against cumulative targets, 2009–2014. Number of key populations (known as MARP until 2013) reached with individual and/or small group level HIV preventive interventions that Number of MARPs/key populations reached with individual- and/or are based on evidence and/or meet the minimum standardsProVIC required results: 2009–2014 small group-level HIV preventive interventions that are based on evidence and/or meet the minimum standards required. Number of the targeted population reached with individual and/or smallNumberNumber group-level of of individuals the preventivetargeted who population receivedinterventions HIVreached testing that withare and based individual counseling on evidence- and/or (HTC) services forand/or HIV meetand received the minimum their test results Numbersmall ofgroup individuals-level preventive who received interventions testing and that counseling are based services on evidence forand/or HIV andmeet received the minimum their test standards results. required. Number of people reached with individual, small group, or community-level intervention or service that explicitly addresses GBV NumberNumber of pregnant of people women reached with with known individual HIV status-, small (includes group- ,women or who were tested for HIV(TOTAL) and received their results) communityNumber of-level pregnant interventions women withor services known thatHIV statusexplicitly (includes address women who were GBVtested and for coercion. HIV and [TOTAL]received their results plus known positives at entry). Number of key populations (known as MARP until 2013) reached with individualPercentage and/or small of HIV-positive group level pregnant HIV preventive women interventions who received that Number of MARPs/key populations reached with individual- and/or are antiretroviralbased on evidence medication and/or (ARV) meet to the reduce minimum risk for standards mother-to-child- required smallPercentage group-level of HIV- preventivepositive pregnant interventions women that who are received based on transmission (MTCT) during pregnancy and delivery antiretroviralevidence and/or medication meet the to reduceminimum risk standards for mother required.-to-child- transmission during pregnancy and delivery. Number of individuals who received HIV testing and counseling (HTC) Number ofservices health for facilities HIV and providing received antenatal their test care results services that Number of individuals who received testing and counseling services include both HIV testing and antiretroviral medication for PMTCT on Number of forhealth HIV facilitiesand received providing their antenataltest results. care services that include both HIV testing andsite antiretroviral medication for PMTCT onsite. Number of pregnant women with known HIV status (includes women Number whoof adults were and tested children for HIV with and advanced received HIV their infection results) receiving Number of pregnant women with known HIV status (includes antiretroviral therapy (ART) [CURRENT] womenNumber who of wereadults tested and children for HIV andwith received advanced their HIV resultsinfection plus receivingknown antiretroviral positives therapy. at entry). [CURRENT]

Percentage of HIV-positive pregnant women who received antiretroviralPercentageNumber ofmedication of eligible HIV-positive children (ARV) pregnant to provided reduce women withrisk for educational who mother-to-child- received and/or antiretroviraltransmission medication (MTCT)vocational to during reduce pregnancy training risk for mother and delivery-to-child- Number of eligible children provided with educational and/or transmission during pregnancy and delivery. vocational training. Number of health facilities providing antenatal care services that include both HIV testing and antiretroviral medication for PMTCT on NumberProportion of healthof PLWHA facilities in HIV providing clinical care antenatal who were care screenedservices for tuberculosis (TB) symptomssite at the last clinical visit Proportionthat include of PLWHA both HIV in testingHIV clinical and careantiretroviral who were medication screened for for TB symptomsPMTCT at the onsite.last clinical visit. Number of adults and children with advanced HIV infection receiving antiretroviral therapy (ART) [CURRENT] Number of adults and children with advanced HIV infection 0% 100% receiving antiretroviral therapy. [CURRENT] % Achievement

Number of eligible children provided with educational and/or vocational training Number of eligible children provided with educational and/or ProVIC’s major achievements—somevocational training. of which represent significant systemic changes—along with key

PEPFARProportion indicators of PLWHA for in HIV each clinical intermediate care who were screenedresult area for are listed below (PEPFAR indicator numbers are tuberculosis (TB) symptoms at the last clinical visit notedProportion in parentheses; of PLWHA in HIV e.g., clinical P8.1D). care who were screened for TB symptoms at the last clinical visit. Prevention, HIV testing and counseling, and prevention of mother-to-child 0% 100% transmission of HIV % Achievement Accomplishments related to ProVIC’s Intermediate Result 1 are summarized below. Following each program area are outcome indicators used to measure achievement. These are cumulative over the life of the project, 2009–2014.

Mobilized and reinforced the ability of communities to develop and implement HIV prevention strategies, using the CC approach tailored for the DRC. ProVIC created a community-owned network

x of HIV/AIDS prevention, care, and support interventions to address underlying causes of vulnerability and create sustainable changes in behavior. The CC approach increased community demand for HTC and PMTCT services and improved care and support for PLWHA. Further, it was tailored to engage and empower key populations—particularly MSM and CSW. The number of MSM and CSW who sought services through the key population CC model was higher than the number who sought services outside the CC model. Over the life of the project, ProVIC and local nongovernmental organization (NGO) partners reached nearly 1.6 million people with HIV prevention interventions through activities carried out by 49 CCs.

Prevention indicators • 1,669,378: Number of the targeted population reached with individual- and/or small group-level preventive interventions that are based on evidence and/or meet the minimum standards required (P8.1D). • 403,353: Number of the targeted population reached with individual- and/or small group-level preventive interventions that are primarily focused on abstinence and/or being faithful and are based on evidence and/or meet the minimum standards required (P8.2D, subset of P8.1D). • 215,921: Number of MARPs/key populations reached with individual- and/or small group-level HIV preventive interventions that are based on evidence and/or meet the minimum standards required (P8.3D). • 66,063: Number of people reached with individual-, small group-, or community-level interventions or services that explicitly address gender-based violence and coercion (P12.5D).

Expanded community- and facility-based HTC services. Central to ProVIC’s approach to offering integrated HIV services was the expansion of HTC services (1) within health facilities through PITC, and (2) at the community level through community outreach by social workers and mobile testing. Over five years, ProVIC provided HTC to 663,817 clients.

HTC indicators • 663,817: Number of individuals who received testing and counseling services for HIV and received their test results (P11.1D). • 27,177: Number of individuals who tested HIV positive (non-PEPFAR indicator).

Expanded and improved PMTCT services: • Increased access to and uptake of comprehensive PMTCT/ART services from FY2010 through FY2014. ProVIC initiated PMTCT activities at 16 health facilities in 2010 in the project’s four operating provinces. By FY2014, that number expanded to 112 health facilities. In addition, there was a continuous increase in the number of pregnant women tested for HIV and the number of known HIV-positive pregnant women who received antiretroviral medications (ARVs). ProVIC provided ARVs to 3,708 HIV-positive pregnant women over the lift of the project to reduce the risk of mother- to-child transmission. • Increased the promotion and uptake of pediatric testing and ART services. Retaining mother-infant pairs in PMTCT and HIV care services is a significant challenge in the DRC. ProVIC established indicators that could act as a proxy for mother-infant pairs, such as infants on cotrimoxazole (CTX) within two months. Progressive improvements were noted in EID, with an observed increase in the number of HIV-exposed infants tested for HIV within 12 months of birth—from 18 in FY2010 to 524

xi in FY2014. The number of infants placed on CTX within two months of birth also increased over time, from 71 infants in FY2011 to 243 infants in FY2014.

PMTCT indicators • 193,685: Number of pregnant women with known HIV status (includes women who were tested for HIV and received their results plus known positives at entry) (P1.1D). • 83.9%: Percentage of HIV-positive pregnant women who received antiretroviral medication to reduce risk for mother-to-child-transmission during pregnancy and delivery (P1.2D). • 3,708: Number of HIV-positive pregnant women who received antiretroviral medication to reduce risk for mother-to-child-transmission during pregnancy and delivery (P1.2D). • 112: Number of health facilities providing antenatal care services that include both HIV testing and antiretroviral medication for PMTCT onsite (P1.3D).

HIV care, support, and treatment

Accomplishments related to Intermediate Result 2 are summarized below. Care and support services strengthened for PLWHA. In collaboration with local partners, ProVIC provided health care and support services to PLWHA from 49 CCs across 112 health facilities in the provinces of Katanga, Kinshasa, Sud Kivu, Bas-Congo, and Orientale. In addition, ProVIC provided nutritional support, counseling to reduce HIV transmission, psychosocial support through the establishment of 162 self-help groups, and mother-to-mother mentoring to encourage mother-child retention in PMTCT services.

Care and support for OVC strengthened. An average of 10,232 OVC were provided with at least one care service each year. These consisted of access to educational and vocational training, food and nutritional support, clinical services, including ART for those who tested positive, and psychosocial support from C2C clubs.

Improved HIV treatment in target areas. ProVIC provided a high-quality package of services to ensure that standards of care were consistent with the DRC government’s national guidelines on ART. ProVIC- supported health facilities worked to improve the early identification of HIV-positive patients who were eligible for treatment. Pediatric ART was initiated in 28 hub sites (reference hospitals). ProVIC supported linkages between community- and clinic-based facilities to enhance timely testing and reduce the time lag between diagnosis and access to care, support, and treatment. By the end of FY2014, ProVIC supported an active cohort of 4,209 individuals on ART.

Care and support indicators ProVIC tracked a number of PEPFAR indicators related to care, support, and treatment on an annual basis. Details on the project indicators for HIV care, support, and treatment can be found in the Intermediate Result 2 section of Section B. A select list of indicators and achievements for FY2014 include: • 4,209: Number of adults and children with advanced HIV infection receiving ART.*

* Active cohort as of September 2014 per Tier.Net.

xii • 22,653: Number of eligible adults and children provided with a minimum of one care service (C1.1D). • 13,351: Number of HIV-positive adults and children who received a minimum of one clinical service (C2.1D). • 63,202: Number of GBV service encounters at a health facility (P12.6D). • 79.3%: Percentage of PLWHA who were screened for TB in HIV care or treatment setting (C2.4D).

Strengthening of health systems supported

Accomplishments related to Intermediate Result 3 are summarized below, followed by the relevant indicator. Below that, Table 1 contains a list of the tools and assistance ProVIC provided to the DRC’s MOH/PNLS (Program Nationale de Lutte Contre Le SIDA, National HIV/AIDS Program). Strengthened the capacity of provincial government health systems. To support sustainable health systems and health care services in the DRC, ProVIC worked to strengthen the provincial government’s capacity throughout the project period. The 28 ProVIC-supported health zones were provided with information technology equipment, office supplies, and financial assistance to support management and coordination functions. In addition, ProVIC: • Improved coordination. After conducting an assessment to identify service gaps, ProVIC—in coordination with the PNLS and Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (National Multi-Sectorial Program for the Fight against AIDS)—developed a capacity-building plan which provincial entities approved. Coordination was a key weakness identified by the assessment as a challenge across all provinces. ProVIC consequently strengthened coordination within and among government agencies and with implementing partners by organizing quarterly coordination meetings at the provincial level. • Identified barriers to care. ProVIC conducted another assessment of health-seeking behaviors in project provinces to better understand the motivations and barriers for clients to access services. They revealed that difficulty in finding effective and affordable health care was the main barrier preventing people from accessing services. The findings underlined the importance of CCs and volunteers in mobilizing communities and referring and bringing clients to health facilities. Survey results were disseminated and formed the basis of ongoing efforts to continue strengthening referral networks. • Provided training. Throughout the project, ProVIC provided training on a variety of health and management topics: a total of 4,449 service providers were trained in topics relevant to project interventions, such as comprehensive PMTCT, HTC, and care and support services for PLWHA and OVC.

Strengthened the capacity of NGO providers. ProVIC’s strategy to strengthen community response to HIV was carried out in partnership with 14 local NGO implementing partners, which established CCs, self-help groups, C2C groups, and networks of community volunteers to increase services provided to beneficiaries. To enhance the work of these partners and to ensure the sustainability of interventions, ProVIC strengthened the groups’ capabilities to implement high-quality programs effectively and efficiently. Enhancing adherence to USAID rules and regulations was a key objective. Efforts focused on improvements in financial management, administrative systems, and monitoring and evaluation (M&E). With capacity-building support from ProVIC, local implementing partners successfully carried out their scopes of work and established CCs that provided essential services to beneficiaries in their communities.

xiii Following the conclusion of community mobilization activities and ProVIC’s support to NGO partners, the project worked with NGO partners to transition CCs to existing community structures.

Strengthened strategic information systems at the community and facility levels. ProVIC’s efforts to strengthen strategic information systems focused on two objectives: (1) building a strong project M&E system; and (2) improving community, facility, and national strategic information systems for monitoring and reporting on the DRC’s and PEPFAR’s responses to the HIV epidemic. While developing a strong M&E system to report on PEPFAR indicators, ProVIC ensured that DRC national guidelines and indicators were included. To ensure sustainability, the project built the capacity of staff in health facilities and NGOs to collect and report high-quality data for both project and DRC information systems.

Provider training indicator “Strengthening of health systems supported” was quantitatively measured by one key indicator. The achievement below is for the life of project, 2009–2014. • 1,609: Number of health care workers who successfully completed an in-service training program.

Table 1. Tools and assistance provided to the DRC MOH/PNLS. Area of focus Tools, approaches, and policies Community mobilization tools • Operational manual on the CC approach. and approaches • Updates to the peer education module, with a focus on key populations. • Pictorial job aides on PMTCT for community outreach workers (incorporates counseling on gender-based violence). HIV testing and counseling • Facilitator training guide on PITC at health care facilities. tools • Pocket guide for provision of PITC for health facility workers.

Care and support tools, • Training module for caregivers on providing care and support services for approaches, and policies OVC. • 2014 OVC operational action plan. • Training-of-trainers manual on the C2C approach. • Terms of reference governing national coordination of OVC. • Contribution to the development of a national child protection policy. • National protocol on nutritional support for PLWHA. • Care and support counseling cards for community-level care providers. Prevention of mother-to-child • National plan for the elimination of mother-to-child transmission of HIV in transmission of HIV tools, the DRC. approaches, and policies • Training materials for the Mentor Mothers approach. • Integration of PMTCT and pediatric care elements into maternal, newborn, and child health (MNCH) technical documents. • Poster on the integration of PMTCT/ART/MNCH for health care providers. • Technical contribution to the production of documents/standards on Option B+. • Integration of Option B+ into family kits. • Technical contribution to the development of a manual on performance- based financing in the DRC. • Pictorial job aides for health facility staff on provision of PMTCT services. • PMTCT counseling cards for health facilities.

xiv Key Challenges

ProVIC faced a number of challenges, which are detailed in Section D. The three most challenging issues faced during implementation are summarized below. 1. Sustaining community activities following the end of ProVIC support: One of the most significant challenges ProVIC faced was the ability of a community to sustain the interventions introduced under ProVIC. Through the CC approach, ProVIC engaged communities in developing and implementing comprehensive HIV prevention, care, and support activities. The ultimate success of this approach depends on the ability of communities to sustain these community-based interventions and the engagement of the Champion Community Steering Committees (CCSCs). ProVIC found that five years was not sufficient time to establish and strengthen a community-based group into a sustainable entity, particularly in communities where community cohesion was not strong and where CCSCs had limited organizational capacities: in these communities, CCSCs dissolved or disbanded after reaching their established annual health goals and following termination of support from ProVIC. ProVIC developed and guided CCSCs through a comprehensive exit plan (transitioning the committees to existing health center committees [COSAs] or community health and development committees [CODESA]) to ensure sustainability of the CC structure and continuity of community- based services. But the capacity of COSAs and CODESAs varied, and sustainability efforts were mixed and reflective of the limited capacity and resource base of these two types of committees. 2. Managing and documenting referrals between community- and facility-based services: In the DRC, management and documentation of referrals from one service provider to the next is often not completed. The MOH estimates that only 2% of referrals overall (not just HIV related) are documented correctly. Referrals and documentation of referrals were thus a major challenge faced by ProVIC. To address this, ProVIC worked with the PNLS to develop a system based on referral slips and follow-up strategies. This included coaching health care workers in all ProVIC-supported health facilities to use the slips and employ follow-up/counter-referral strategies. Throughout implementation, ProVIC actively worked to improve the referral system, through targeted technical assistance and follow-up (please refer to sub-IR 3.1 for more information). 3. Reaching key populations: Reaching key populations, particularly MSM and CSW in DRC, is a priority for PEPFAR, and it was critical to the success of ProVIC, which sought to provide MSM and CSW with testing, referral, and treatment services. At the same time, ProVIC had another priority: the deliberate engagement and strengthening of the DRC’s central health zones as crucial players in the fight to reduce HIV transmission. However, providing services to MSM and CSW, many of which are highly mobile, in their health zones and communities proved to be difficult. Instead, ProVIC found that members of these key population groups were best reached in urban areas, through provision of nighttime testing, counseling, and referrals in “hot spots,” then followed up to make sure they could conveniently access care and treatment—not necessarily in their home health zone.

xv A. Introduction

This section presents general information on the project, including methodology and contract mechanism, objectives, and framework, and also provides a historical narrative of the phases of Projet Integré de VIH/SIDA au Congo (ProVIC, USAID’s flagship Integrated HIV/AIDS Project in the Democratic Republic of Congo).

Background

The Democratic Republic of Congo (DRC) is ranked as one of the least developed country in the world (186/187) according to the United Nations Development Programme.i The size of the population, inaccessible geography, scale of poverty, and decades of conflict have resulted in the lack of a cohesive and functional health system.ii

The US Agency for International Development (USAID), through the US government’s Global Health Initiative and US President’s Emergency Plan for AIDS Relief (PEPFAR), created ProVIC as USAID’s flagship project in the DRC to address the HIV/AIDS epidemic as part of USAID’s larger mission to support development and humanitarian efforts in the country. USAID’s role in the national response is directly aligned with the Ministry of Health’s (MOH) Plan Nationale pour le Development Sanitaire (National Health Development Plan) for 2011–2015.

Although HIV prevalence in the DRC has remained essentially stable since 2003, there is a heterogenic distribution of virus marked by variation across different regions and populations. According to the 2013 Demographic and Health Survey,iii the prevalence of HIV in the DRC is 1.2%, with the rates in ProVIC- supported provinces at 1.6% for Kinshasa, 1.5% for Katanga, 2.3% for Orientale, 0.2% for Bas-Congo, and 0.4% for Sud Kivu (see map, page 7).† The gender disparity in HIV prevalence between men and women 15–49 years of age is significant, at 1.6% for women compared to 0.6% for men. Urban prevalence rates are nearly double rural prevalence rates, at 1.6% and 0.9% respectively.iii

Despite the long period of instability in the country, efforts have been made to reduce the spread of HIV and mitigate its impact on communities. The Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (PNMLS, National Multi-Sectorial Program for the Fight against AIDS) is the institutional framework for the coordination of a multi-sectorial response to HIV/AIDS in the DRC. The Program Nationale de Lutte Contre Le SIDA (PNLS, National HIV/AIDS Program) is the technical arm of the MOH responsible for integrating clinical services into the national health system.

† Recognizing the low prevalences in Sud Kivu and Bas-Congo, PEPFAR oriented ProVIC to withdraw and transfer activities to the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2013 (Sud Kivu) and 2014 (Bas-Congo).

1 Project monitoring and evaluation system and framework

ProVIC’s goals are organized into the ProVIC Results Framework (Figure 2), which serves as a planning, management, and communications tool. ProVIC’s overall objective is to reduce the incidence and prevalence of HIV/AIDS and mitigate its impact on people living with HIV/AIDS (PLWHA) and their families. This project objective is accomplished by carrying out three intermediate results (IRs), which are further divided into sub-intermediate results (sub-IRs) that drive project activities. The project objective, in turn, contributes toward accomplishing the US government’s goal of improving the basic health conditions of the Congolese people. In addition to functioning as an organizing mechanism to guide project implementation, the Results Framework serves as the link between annual work plans and the Performance Monitoring and Evaluation Plan (PMEP). The PMEP sets indicators, which are aligned with PEPFAR indicators, and targets by intermediate result and sub-IR to measure progress made toward accomplishing project goals.

Over the past five years, ProVIC’s Results Framework, PMEP, and monitoring and evaluation (M&E) indicators have changed to align with the project’s technical and programmatic shifts, which are detailed in the following section. ProVIC’s data collection system is based on datacards, which record data based on the project’s established indicators. These datacards are completed by ProVIC-supported nongovernmental organization (NGO) and health facility partners and submitted to ProVIC on a monthly basis. The data recorded in the project’s datacards are then uploaded into ProVIC’s online M&E database, built on the Salesforce platform, which enables the M&E team to track timely progress made toward established targets and to analyze trends. More information on ProVIC’s M&E system and activities, including efforts to strengthen strategic information systems at the community and facility levels, is provided under Intermediate Result 3.

2 Figure 2. ProVIC Results Framework.

United States government goal: Basic health conditions of Congolese people improved

Project objective: Reduce the incidence and prevalence of HIV/AIDS and mitigate its impact on PLWHA and their families

Intermediate Result 1: Intermediate Result 2: HIV testing and counseling Care, support, and Intermediate Result 3: and prevention services treatment for PLWHA and Strengthening of health expanded and improved in OVC improved in target systems supported target areas areas

Sub-IR 1.1: Sub-IR 3.1: Communities’ ability to Sub-IR 2.1: Capacity of provincial develop and implement Care and support services government health prevention strategies strengthened systems supported strengthened

Sub-IR 1.2: Community- and facility- Sub-IR 2.2: Sub-IR 3.2: based HTC services Care and support for OVC Capacity of NGO increased and enhanced strengthened providers supported

Sub-IR 3.3: Sub-IR 2.3: Strategic information Sub-IR 1.3: HIV treatment improved systems at community PMTCT services improved in target areas and facility levels strengthened

HTC: HIV testing and counseling; OVC: orphans and vulnerable children; PMTCT: prevention of mother-to-child transmission of HIV.

3 Historical evolution of ProVIC: 2009–2014

Due to the many changes in ProVIC’s technical approach and scope over the past five years, the project is best described in three phases (Figure 3).

Phase 1: (October 2009–July 2012)—Community-level prevention and impact mitigation with linkages Need to give more explanation to the different phases of the project, especially the strategic pivot and changes applied to the project following the mid-term review to health facilities through the CC approach.

Phase 2: (July 2012–March 2013)—Acceleration and expansion of prevention of mother-to-child transmission of HIV (PMTCT) and expansion to include gender-based violence (GBV) activities and Province Orientale.

Phase 3: (March 2013–September 2014)—Support for the PEPFAR Strategic Pivot to care and treatment and ProVIC expansion to 112 health facilities.

Figure 3. ProVIC phases and scale, FY2010–FY2014.

120

100

80

60

40

20

0 FY2010 FY2011 FY2012 FY2013 FY2014

Phase 1 Phase 2 Phase 3

Number of ProVIC provinces Number of champion communities Number of health zones Number of health facilities

Phase 1: (October 2009–July 2012)—Community-level prevention and impact mitigation with linkages to health facilities through the Champion Community approach PATH was awarded ProVIC and began implementing activities with consortium partners Chemonics International, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), the International HIV/AIDS Alliance, and Catholic Relief Services in four provinces: Kinshasa, Katanga, Sud Kivu, and Bas-Congo. Inheriting beneficiaries and activities from USAID’s previous HIV/AIDS project, RESA+, ProVIC’s start-up period was focused on balancing the provision of services to existing beneficiaries, training service providers, and developing new partnerships and interventions focused on piloting and scaling up the innovative CC approach. By 2011, ProVIC had established 40 CCs, each covering communities of 10,000–40,000 inhabitants, which created a community-level platform of integrated services by which

4 CCs self-identified local drivers of the epidemic and implemented action plans with the support of ProVIC’s technical staff and inputs.

Prevention interventions were diffused through myriad local actors, including churches, the government, youth groups, and women’s groups, while testing and counseling services were offered at the health facility and community levels, both through standalone community sites and mobile HIV testing and counseling (HTC). In each community, key populations of men who have sex with men (MSM) and commercial sex workers (CSW), as well as priority populations of truck drivers, miners, and fishermen, were specifically targeted to receive mobile services in the places where they convened. In the case of MSM and CSW, this meant nighttime testing and counseling in urban “hot spots.” Individuals who tested HIV positive were referred directly to local health facilities for care and were enrolled in a set of supportive community-level services and interventions that included palliative care, psychosocial support via self-help groups, home visits, and income-generating activities (IGAs). Orphans and vulnerable children (OVC) were offered a package of services that included education support, psychosocial support through C2C groups, referrals for clinical services, and legal support.

ProVIC supported 16 health facilities during Phase 1, primarily with interventions focused on a comprehensive package of PMTCT.

Phase 2: (July 2012–March 2013)—Acceleration and expansion of prevention of mother-to-child transmission of HIV and expansion to include gender-based violence activities and Province Orientale In 2012, ProVIC’s technical emphasis and geographic focus shifted. PEPFAR’s global PMTCT Acceleration Initiative was introduced to scale up PMTCT interventions with the objective of reducing the burden of mother-to-child transmission and protecting the lives of mothers. The DRC’s participation in the PMTCT Acceleration Initiative resulted in the rapid increase in ProVIC-supported PMTCT sites from 16 to 44 health facilities offering comprehensive PMTCT. This was accomplished through a “hub and spoke” model, whereby health clinics served as spokes to the additional services available at the hub, which was usually a general reference hospital. In support of the PMTCT activities, ProVIC designed and implemented the Mentor Mother approach, whereby trained HIV-positive mothers offered psychosocial support and adherence counseling to their peers at the health facility level. After jointly developing the approach with the PNLS, it was piloted in 19 health facilities in 2013 and expanded to replace the broader CC approach as ProVIC’s main linkage between the health facilities and communities.

ProVIC also expanded to include GBV activities. GBV prevention activities were implemented through CCs to help change harmful norms that lead to gender-based violence and share information about available GBV services. Geographically, the program expanded when ProVIC initiated PMTCT activities in 12 health facilities in Kisangani, Province Orientale.

In this phase, ProVIC adapted the original CC approach to key populations specifically. ProVIC created CCs around networks of MSM and CSW within a particular urban area to better reach these key populations.

5 Phase 3: (March 2013–September 2014)—Support for the PEPFAR Strategic Pivot to care and treatment and ProVIC expansion to 112 health facilities In March 2013, USAID/PEPFAR announced that the DRC would be pivoting from the PMTCT platform to a program focused on expanding access to care and treatment. Through a series of antiretroviral therapy (ART) trainings facilitated with the PNLS, ProVIC transformed itself into a treatment program, scaling up from 44 sites in 2012 to 103 by the end of 2013. Through the end of 2013 and through 2014, ProVIC continued to enhance its adult and pediatric treatment program, progressively adding layers of quality assurance/quality improvement (QA/QI) and community linkages to care through expansion of the Mentor Mother program. By September 2014, ProVIC was supporting a cohort of 3,888 individuals on ART.

In alignment with the Strategic Figure 4. DRC health system—the health care pyramid. Pivot’s focus on treatment and facility-based services, ProVIC progressively decreased support Central (national) level - Primary for CCs, ending all support by function is to design, plan, and coordinate national health policy and March 2014 (please refer to sub- actions. IR 1.1 for additional details). The CC approach helped establish Intermediate (provincial) level - Role is to linkages between communities support the coordination and supervision of and local health facilities, and health zone teams to ensure better ProVIC utilized these existing implementation of health policy. linkages during this phase to disseminate messaging around Peripheral (health zone) level - Primarily operationalizes and implements national access to and availability of health care strategies. Each health zone is PMTCT, GBV, and family composed of a central administrative office, a planning services in local ProVIC- general reference hospital (hub), and a network of health centers (spokes). supported health facilities.

During this phase, ProVIC also operationalized recommendations by USAID to strengthen the peripheral (health zone) level of the DRC system by purposefully engaging health zones in project implementation. ProVIC provided financial and technical support to 28 health zones and engaged with government entities at the national and intermediate (provincial) level. Figure 4 provides an overview of the DRC’s health care system and outlines the responsibilities of the three levels.

USAID/PEPFAR also announced strategic changes to ProVIC’s intervention provinces. Sud Kivu and later Bas-Congo were identified as lower-priority provinces due to their low HIV prevalence. In October 2013, ProVIC closed its activities in Sud Kivu, transferring support of beneficiaries to the Global Fund. In 2013, ProVIC also stopped support to community-level activities in Bas-Congo, maintaining support to health facilities through FY2014.

ProVIC’s operational presence

Over the course of the project, ProVIC supported 49 CCs and 112 health facilities across the following five provinces of the DRC: Kinshasa, Katanga, Orientale, Bas-Congo, and Sud Kivu (Figure 5).

6 Figure 5. Map of the DRC showing ProVIC’s presence and HIV prevalence by province.

Legend

ProVIC presence

Project offices

X% Average HIV prevalence rate by province (15–49 years of age)

Evolution of ProVIC’s geographic presence

FY2010–FY2011: Kinshasa, Katanga, Bas Congo, Sud Kivu FY2012–FY2013: Kinshasa, Katanga, Bas Congo, Sud Kivu, Orientale FY2014: Kinshasa, Katanga, Bas Congo, Orientale

7 B. Achievements

Intermediate Result 1: HIV testing and counseling and prevention services expanded and improved in target areas

Sub-IR 1.1: Communities’ ability to develop and implement prevention strategies strengthened ProVIC engaged communities to develop and implement comprehensive HIV prevention, care, and support activities, encouraging community ownership and sustainability of HIV interventions. The primary strategy ProVIC used to mobilize communities around the provision of HIV services was the CC approach. The following three components of this approach summarize ProVIC’s key activities to strengthen communities’ capacity to develop and implement HIV strategies: bringing community actors together to introduce, advocate, and plan at the community level; training community actors to conduct HIV prevention activities; and building community capacity to review and evaluate prevention strategies.

Over the life of the project, ProVIC and local NGO partners reached nearly 1.6 million people through activities carried out by 49 CCs.

Evolution of community mobilization activities ProVIC’s community mobilization efforts changed over time with the project phases (described in the Introduction). During the first phase of the project, ProVIC worked to rapidly scale up the CC approach and establish 44 CCs. During Phase 2, ProVIC adapted the CC model to better target key populations (MSM and CSW) with outreach and mobilization within the original CCs as well as establishing five “key population” CCs, for a total of 49 CCs. With the Strategic Pivot and Phase 3, ProVIC gradually reduced support to CCs. Toward the end of FY2013, 22 CCs without a project-supported PMTCT site in their health zone were discontinued, and at the end of Q2 FY2014, the remaining 27 CCs were transferred to 18 health zones. ProVIC developed and guided CCs through a comprehensive exit plan to ensure sustainability of the CC structure and continuity of services and support to PLWHA and OVC following the end of ProVIC’s funding (further explained under sub-IR 3.2). Figure 6 illustrates the number of CCs support by ProVIC per fiscal year and the scale-up and reduction of community mobilization activities.

Figure 6. Number of ProVIC-supported CCs by fiscal year, October 2009–March 2014.

CCs scaled up Key population CCs CCs transitioned to health zone 60

50

40 Number PEPFAR Strategic Pivot of 30 CCs 20

10

0 FY2010 FY2011 FY2012 FY2013 (Q1-Q2) FY2013 (Q3-Q4) FY2014 (Q1-Q2)

8 Results ProVIC worked intensively with 44 CCs and five key population CCs through the first two quarters of FY2013 before ending support to all CCs at the end of the 2nd quarter of FY2014. In collaboration with our NGO partners, ProVIC trained an average of 55 community stakeholders in each CC—40 community actors (volunteers, peer educators, community workers) and 15 community leaders—on HIV/AIDS, family planning, GBV knowledge and communication techniques, and the CC approach. Through group discussions, door-to-door outreach, and peer education, ProVIC reached 1,669,378 individuals with preventive interventions, of which 403,353 were provided with preventive interventions primarily focused on abstinence and/or being faithful. ProVIC also targeted most at-risk populations (MARPs) with preventive messaging, including 60,270 members of key population groups, such as MSM and CSW; 137,441 members of priority populations, such as truck drivers, fishermen, and miners; and 18,210 members of other vulnerable populations, such as the uniformed services (policemen and military) and clients of CSW. Figure 7 illustrates the proportion of each population reached with prevention messages.

Figure 7. Number and percentage of individuals by category reached with prevention messages, October 2009–September 2014.

137,441 18,210 7% 1%

60,270 3%

1,669,378 89%

General population Key populations Priority populations Other vulnerable populations

Figure 8 shows the number of individuals in the general population targeted and reached with individual and/or small group preventive interventions by fiscal year, and Figure 9 shows the number of MARPs targeted and reached with preventive interventions by fiscal year. The results shown in both figures illustrate the shift in PEPFAR’s priorities over time, with ProVIC Phase 1 focused on broad community mobilization and outreach, thus higher numbers of people reached in the general population. By 2012 (Phase 2), prevention activities were reduced for the general population but continued for key and priority populations. By Phase 3, prevention activities with the general population were reduced, while prevention activities with key and priority populations also decreased as ProVIC resources continued to shift toward clinical care and treatment services.

9 Figure 8. Number of individuals reached with prevention messages, October 2009–September 2014.

600,000 543,940

500,000 443,692

400,000

316,302 Number of the 284,215 300,000 population

200,000

100,000 81,229

- FY2010 FY2011 FY2012 FY2013 FY2014 Annual target

Figure 9. MARPs reached with prevention interventions by fiscal year, October 2009–September 2014.

80,000 74,621 70,000 58,791 60,000 50,000 Number of 43,247 MARPs reached 40,000 30,706 30,000 20,000 8,556 10,000 - FY2010 FY2011 FY2012 FY2013 FY2014

Annual target

10 Throughout the first three years of ProVIC, there was not a significant difference between the number of women and men reached with prevention messages. However, with the pivot toward PMTCT in 2014, the proportion of women increased, as depicted in Figure 10.

Figure 10. Number of males and females reached with prevention messages, October 2010– September 2014.

350000 317,204 301,357 300000 236,521 250,418 250000 200000 178,384 Number of 164,622 individuals 150000 reached 100000 70,027 50000 18,439 0 FY2011 FY2012 FY2013 FY2014

Male Female

Summary of interventions Building community capacity through CCs The CC approach, selected based on positive results from the Santé Net project in Madagascar, sought to create a sustainable, community-owned network of HIV/AIDS prevention, care, and support interventions to address underlying causes of vulnerability and create sustainable changes in behavior. The approach encouraged local participation in planning, implementation, and M&E; empowered communities to demand access to HIV services; and ensured the Sustainability of commitment of all actors in the community. ProVIC Champion Community activities adapted the CC approach for the DRC context and used it With the CC approach, we learned that there are so many resources at our disposal just waiting to be to increase community demand for HTC and PMTCT used. We had gotten into the habit of thinking of services and improve care and support for PLWHA. In resources in terms of finances strictly for implementation of HIV/AIDS activities in our addition to providing a platform to reach the general communities. Nevertheless, the capacity building population, the CC approach provided a mechanism we received from ProVIC at the community actor level are a valuable asset for the ownership and through which ProVIC could reach key populations and sustainability of activities in that certain CCs were brought communities together to address the challenge of able to benefit from micro-financing. Now, we can implement activities without having to rely upon stigmatization and discrimination faced by these groups external resources. when seeking testing and treatment services. By ─ Eddy Sasi Panzu, JADISIDA Coordinator strengthening relationships between community actors and points of service delivery, such as health centers, ProVIC built the capacity of communities to effectively respond to and mitigate the impact of HIV and to take ownership of prevention and treatment activities. For more information on the CC model, please refer to the PEPFAR-supported AIDSTAR-One case study titled ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo.iv

Adaptation of the CC approach At the beginning of the project, ProVIC worked with 14 local NGOs to implement the CC approach. To better engage and reach the communities, the first adaptation of the CC approach, the “Kisangani model,” was launched in 2013, through which ProVIC worked directly with CCs rather than through local NGOs.

11 The second adaptation of the CC approach was to tailor it to better reach key populations. Recognizing that HIV prevalence in the DRC was extremely high among MSM (prevalence of 11%),v it became evident that the needs of this stigmatized population would not be served through the original CC model. Many key populations, such as MSM, are spread across urban areas and defined by economic and social characteristics rather than neighborhood borders. To expand the reach of HTC services, ProVIC collaborated with local organizations that were already working with key populations (e.g., Kinshasa- based MSM peer educators) to adapt the CC model, creating communities around a population group rather than a geographic area. During this collaborative effort, ProVIC reviewed relevant studies and national reports, conducted interviews with key informants, and held focus group discussions with targeted population members to map key populations within an urban area. Through this mapping exercise, ProVIC identified key population networks and followed the CC approach to establish steering committees, develop action plans, set targets, and train peer educators. The key populations CC approach implemented activities with the needs of MSM and CSW in mind, including messaging on stigma, discrimination, human rights, and the specific prevention and care needs of MSM and CSW. These key population CCs also worked to identify MSM- and CSW-friendly health facilities, which were provided with appropriate medical equipment to meet the needs of these groups.

By engaging key populations through the CC approach, ProVIC was able to more effectively access key populations and empower individuals to embrace self-affirming identities that countered stigmatizing stereotypes. Participants embraced and supported each other as mothers, brothers, skilled professionals, and Topics included in prevention messages by Champion Community outreach workers neighbors. Through outreach, acceptance, and reduction of stigma, members of these populations were encouraged  Abstinence and being faithful. to view themselves in a positive light. ProVIC also  Condom use. observed that the number of MSM and CSW who sought  Sexually transmitted infections.  Fundamentals of HIV/AIDS. services through the key population CC model was  The importance of getting tested and significantly higher than the number who sought services knowing one’s HIV status. outside the CC model. During Q1 of FY2014, 779 MSM  The role of the community in the fight and 693 CSW visited MSM-friendly or sensitized clinics against HIV/AIDS. in comparison to 89 and 274, respectively, at other sites.  Living HIV positive; care and support for ProVIC presented its approach to key populations at the people living with HIV/AIDS. 2014 International AIDS Conference through a poster,  PMTCT and available services.  The role of key populations in the fight “Re-envisioning the champion communities approach to against HIV/AIDS. better serve urban populations in the Democratic  Fighting stigmatization and discrimination. Republic of the Congo.”vi

Education and outreach ProVIC reached a diverse range of stakeholders and covered an array of important issues through discussion groups, individual and group education sessions, home visits, and demonstrations carried out by relais communautaires (community outreach volunteers), peer educators, and other community actors. These volunteers targeted a variety of groups, including religious and traditional community leaders,

12 teachers, women’s groups, youth, PLWHA, Figure 11. Champion Community cycle. OVC, key populations (i.e., MSM and

CSW), and priority populations (e.g., Mobilize community miners and fishermen). around the CC concept and advocate with Capacity-building community ProVIC successfully built the capacity of leaders Create and train project partners, Champion Community CC Steering Committees on CC Celebrate! Steering Committee (CCSC) members, model, HIV/AIDS, management, and and individual community actors to communication implement the CC approach in line with Annual Champion the needs and unique considerations of Community Cycle their respective communities. Each of these groups was integral to the successful implementation of the CC approach, and Evaluate results Gather data and against establish through trainings, ongoing support, and established objective, targets and targets, and consultation from the project, these key objectives indicators actors were able to implement and oversee Monitor CC activities, understand the CC cycle implementation of activities and and their role in it (Figure 11), use results management information systems and data collection tools, and effectively communicate important information about HIV prevention and testing to members of the community. The intensive capacity-building efforts of the project were critical in promoting the sustainability of CC activities. As a result of the training and experience they received with ProVIC’s support, community actors were able to continue activities after the CCs were integrated into health zones and transitioned from the project.

Sustainable community mobilization To ensure the continuity of CC activities at project end, ProVIC established an exit plan for CCSCs, which consisted of four phases: preparation, execution, support, and phase-out. The CCSCs, after being integrated into their local health zone by either transitioning to community health committees (CODESAs) or establishing themselves as NGOs, continue to work under the supervision of each health zone to ensure that health facilities are linked with community-based actors working toward HIV prevention objectives.

Sub-IR 1.2: Community- and facility-based HIV testing and counseling services increased and enhanced Central to ProVIC’s approach to offering integrated HIV services was the expansion of HTC services within health facilities through provider-initiated testing and counseling (PITC) for patients receiving PMTCT, tuberculosis (TB), sexually transmitted infection (STI), and antenatal care services, and at the community level through community outreach by social workers and mobile testing. ProVIC’s work to enhance community- and facility-based HTC services included the introduction of “moonlight” testing, the provision of key population-specific testing and counseling messages through the key population CCs, facility- and community-based outreach, and use of innovative testing methods.

13 Over five years, ProVIC provided HTC to 663,817 clients.

Evolution of HTC activities ProVIC delivered community-based and mobile HTC services during the first three years of the project to key populations, other priority populations, and subgroups within the general population. In FY2013, following PEPFAR’s Strategic Pivot, the project’s HTC activities largely centered around health facilities, with two NGO partners, Progrès Santé Sans Prix (PSSP, Progress and Health Without a Price) and World Production, offering mobile testing services to key populations in Kinshasa and Katanga, respectively. To support the project’s focus on the HIV continuum of care, including provision of treatment and clinical services, ProVIC selected St. Hilaire Health Center, an MSM-friendly facility, to offer a complete package of HIV services, from testing to treatment and support, to key populations in Kinshasa.

Results As shown in Figure 12, ProVIC provided HTC services to 663,817 clients, of whom 27,177 were seropositive for HIV, a rate of 4.1%. Figure 12a shows the number of clients tested for HIV and seropositivity rates for FY2010 and FY2011, while Figure 12b presents the same information for FY2012–FY2014 at the facility and community levels.‡

Figure 12a. Clients tested for HIV and seropositivity rates, October 2009–September 2011.

180,000 2.9% 160,000 140,000 120,000 100,000 3.8% 80,000 60,000 40,000 20,000 0 FY2010 FY2011 Individuals Tested for HIV Seropositive Individuals

As observed in Figure 12b, seropositivity rates in both facility- and community-level HTC increased from FY2012 to FY2014. ProVIC focused significant effort within that period to improve the quality of HTC services and ensure that those at highest risk of HIV infection were tested and linked to the continuum of care, if HIV positive. In health facilities, ProVIC expanded the provision of PITC to other entry points, including TB, STIs, and in-patients, and additional technical assistance and supportive supervision was provided to health care workers on better targeting of HTC to patients who were symptomatic. The gradual increase in the seropositivity rate at the community level, in spite of a general decrease in

‡ Disaggregated HTC data by setting (clinical versus community) is not available for FY2010 and FY2011.

14 community-level HTC activities carried out under ProVIC, can be explained by the focus of community- level HTC activities on reaching key populations in the latter years of the project, population groups that tend to be at higher risk of HIV infection.

Figure 12b. Clients tested for HIV and seropositivity rates in facility and community settings, October 2011–September 2014.

140,000 4.5% 120,000 4.1%

100,000 3.7%

5.4% 80,000 3.8%

60,000

40,000

20,000 7.9% 0 FY2012 FY2013 FY2014 Facility Community Facility Community Facility Community

Figure 13 shows the type of work conducted by ProVIC partners in 2013, before and after the PEPFAR Strategic Pivot, demonstrating the project’s shift from community- to facility-based HTC. As a result of the Strategic Pivot’s focus on treatment and PMTCT, ProVIC cut all community HTC activities, reduced mobile HTC outings targeting key populations, and expanded PMTCT testing and PITC at other entry points to ensure an easier transition to the continuum of care and follow-on treatment for those who test HIV positive.

Figure 13. Percentage of HTC by approach, before and after the Strategic Pivot.

100% 90% 80% 70% 60% Percentage 50% of HTC by approach 40% 30% 20% 10% 0% Q1/Q2 FY 2013 Q3 FY 2013

PMTCT PITC Community HTC Mobile HTC

15 From 2011 through 2013,§ ProVIC continued to offer HTC services to key populations, other priority populations, and other subgroups of the general population through its partners. Table 2 shows that among key populations, injection drug users (IDUs) and MSM had higher seropositivity rates (17% and 12%, respectively), while the seropositivity rate was 6% among fishermen and 5% each for miners and truck drivers.

Table 2. Seropositivity of key and priority populations. Category Positive Negative Total Seropositivity Key populations IDUs 21 105 126 17% MSM 488 3,472 3,960 12% CSW 1,097 26,562 27,659 4% Priority populations Fishermen 272 4,301 4,573 6% Miners 243 4,400 4,643 5% Truck drivers 1,201 23,100 24,301 5%

Figure 14 shows ProVIC-supported health facilities that had the highest HIV seropositivity rates within each province—that is, the sites in each province that yielded the highest rates (based on PITC). As observed from the figure, the highest rates were found in health structures in Katanga (Kenya General Reference Hospital, 23%, and St. Marcel Health Center, 14%), Orientale (Pumuzika Health Center, 12%), and Bas-Congo (Boma General Reference Hospital, 10%), while the lowest seropositivity rates were found in sites in Kinshasa (Kisangani Maternity Hospital, 2%) and Sud Kivu (Nyatende and Bagira General Reference Hospitals, 2% each).

§ Disaggregated testing data for key populations by province are only available from 2011–2013.

16 Figure 14. ProVIC-supported health facilities with seropositivity rates by province, October 2012– September 2014.

Light HC Bolingani HC Kikimi HC Kingasani MH Kenya GRH St. Marcel HC Chisambu HC Health Awadi HC facility Kasumbalesa HRC Boma GRH Kiamvu GRH Lukula GRH Kinkonzi GRH Pumuzika HC Neema HC Mokili HC Nyatende GRH Bagira GRH Site seropositivity rate (%)

0 5 10 15 20 25

Kinshasa Katanga Bas-Congo Orientale Sud Kivu

Summary of interventions Improving the quality of HTC services in ProVIC’s areas of intervention ProVIC’s outreach services routinely supported community-level interventions; for example, raising awareness of nighttime mobile testing through the use of MSM and CSW peer education and organizing networks and CCs specific to key population groups. Through these CCs, key population members received training to be peer educators and conduct outreach and education within their communities, share knowledge and best practices, promote safe behaviors, and refer other key population members to HTC services where health care providers had been sensitized and they could feel safe and welcome. ProVIC worked closely with local project partner PSSP, which has done intensive outreach among MSM to provide HTC; treatment, care, and support for HIV-positive individuals; and referral for treatment of STIs and opportunistic infections.

To ensure a continuum of response for those who tested positive at ProVIC-sponsored community HTC sessions, HIV-positive individuals were directly referred to health facilities for treatment and care services. Mobile HTC targeting key populations, such as MSM and CSW, were largely carried out by World Production (in Katanga) and PSSP (in Kinshasa). In Kinshasa, MSM and CSW who tested HIV positive were referred to St. Hilaire Health Center, an MSM-friendly facility where patients were provided with care, treatment, and psychosocial support services in a non-discriminatory, non- stigmatizing environment. In Katanga, World Production referred HIV-positive individuals from key populations to specific health care providers at Kenya General Reference Hospital and Kampemba

17 General Reference Hospital, where staff were coached to ensure a non-discriminatory environment. Peer educators and self-help groups associated with health facilities were also critical to supporting referrals/counter-referrals between communities and service providers and ensuring that HIV-positive individuals were linked to care and treatment services.

Moonlight testing One challenge ProVIC found in implementing HTC activities was that MSM, CSW, and other vulnerable groups were often unwilling to seek HTC services due to stigma. To address this challenge, ProVIC spearheaded introduction of nighttime mobile voluntary HTC, or moonlight testing, in partnership with PSSP and using key population mapping done by the Joint United Nations Programme on HIV/AIDS (UNAIDS). Mobile sites increased access to HIV prevention services by reaching people where they lived and worked. ProVIC conducted a risk-mapping exercise to identify MSM and to target HIV hot spots— around bars, nightclubs, and other commercial areas where MSM and FSW typically congregate. Once the project identified sites, peer educators were integral to creating awareness about moonlight testing, times, and locations, and assuring peers that they would be welcome as MSM or CSW and could feel comfortable seeking testing and counseling at the mobile clinics. Onsite, these moonlight mobile clinics offered rapid finger-prick HIV testing so clients received their results quickly. To determine the performance of moonlight HTC in reaching key populations, ProVIC closely monitored activities and regularly collected data. The project concluded that in comparison to prior HTC rates, HTC rates increased following the introduction of moonlight testing, including a 300% increase in MSM participation in HTC after the first month of intervention. ProVIC presented this approach at the 2012 International AIDS Conference, sharing the innovation and impact with the global public health community in a presentation titled “Mobile ‘moonlight’ voluntary HIV counseling and testing for men who have sex with men in Kinshasa, Democratic Republic of Congo.”vii

Training of HTC service providers In addition to improving the access of populations to ProVIC’s HTC services, the project trained service providers in the administration of high-quality HTC services. These service providers included doctors, nurses, laboratory technicians, social workers, and community workers. In total, ProVIC trained 1,609 health service providers within the PNLS and at the provincial level. As a result, these providers had the capacity to train their peers on the correct administration of HIV testing in accordance with national standards. ProVIC worked with staff at the facility, provincial, and national levels to provide follow-up monitoring and support to ensure service quality both for provision of testing and for laboratory quality (see sub-IR 1.3 and IR 3.1).

ProVIC worked with PSSP’s MSM-friendly clinic in Kinshasa and other health care providers at partner clinics to sensitize service providers on providing services to key populations, reduce discrimination and stigmatization against MSM and CSW, and create safe spaces for these populations. As a result, there was a near doubling in the number of MSM and CSW visiting clinics for HIV testing services (from 7,968 in 2012 to 15,368 in 2013). While significantly more CSW received testing than MSM (the number of CSW tested increased from 7,211 to 12,747, while the number of MSM tested increased from 757 to 2,621), the largest percentage increase was among MSM. ProVIC also worked more generally to ensure that all HIV- positive individuals were provided with care and treatment services in a non-discriminatory environment—all health care providers at ProVIC-supported facilities and community outreach workers were trained on an ethical code that obliged service providers to deliver services to patients in a non- discriminatory manner and to respect patient confidentiality.

18 Integrating HTC with other relevant health services ProVIC worked to establish PITC within facility-based services, including inpatient, family planning, TB, and STI testing. Family planning supports practicing safer sexual behaviors to avoid unwanted pregnancies as well as HIV and STIs. At all HTC sites, ProVIC provided clients with family planning information and educational materials as well as commodities such as male and female condoms.

In collaboration with the DRC’s National Tuberculosis Program, ProVIC established systems for referral and counter-referral of clients co-infected with HIV and TB. In 2011, ProVIC carried out a mapping exercise of sites providing TB screening and treatment and shared these maps with local CCs and health facilities to facilitate referrals to TB screening and treatment centers. As part of the referral system, health care providers referred clients with HIV/TB co-infection to ProVIC HTC sites for psychosocial support.

ProVIC also integrated STI testing and counseling into other services, such as PMTCT and HTC services targeting key populations. For example, when MSM sought HTC services at these sites, they were also tested for STIs and subsequently referred for STI-specific counseling and treatment services.

Following the PEPFAR Strategic Pivot, ProVIC increased PMTCT sites and promoted PITC through the PMTCT entry point. The PMTCT program integrated TB and STI testing with HTC, incorporating family planning, HIV treatment, and psychosocial support. ProVIC supported a total of 112 PMTCT sites and provided services to 193,343 pregnant women through the PMTCT program.** By involving partners of pregnant mothers and women of child-bearing age in the PMTCT program, ProVIC was able to more effectively integrate family planning with PMTCT.

Promoting HIV testing technologies by introducing new types of tests, equipment, and other laboratory commodities Within clinical settings, ProVIC worked to enhance testing and counseling services through improved techniques, technologies, and equipment. For example, the project made the finger-prick technique accessible in supported HTC sites, which allowed for HIV testing using modern devices that are quick and simple to use and less painful to clients, and storing of samples for confirmation of results and quality control. ProVIC also procured five portable PIMA™ analyzers, one for each province. By analyzing CD4 counts, these machines were critical in determining whether to put those who tested positive for HIV on cotrimoxazole (CTX) prophylaxis or to refer them for ART. This is described in greater detail under Intermediate Result 2.

ProVIC was committed to minimizing the spread of disease and other health risks of HTC, taking scrupulous measures to promote injection safety and management of biomedical waste. In addition to training health workers and relais communautaires in injection safety, the project provided Masi PATH/F. Photo: appropriate medical supplies and training to all health A client receives a finger-prick HIV test. facilities to support safe injections. Supplies included disposable needles, hazardous waste disposal containers, sterile gloves, alcohol, tourniquets, and bleach and cleaning supplies. ProVIC also invested in

** This figure includes pregnant women who were tested and received a positive test result and known HIV-positives at entry into the PMTCT program.

19 improving waste management systems at several sponsored sites by installing incinerators. To ensure adequate stock of supplies required for biomedical waste management, injection safety, and hygiene, ProVIC continually replenished materials and assessed supply and equipment needs during regular supervisory visits.

Quality assurance ProVIC integrated quality assurance protocols for testing and counseling services in line with PNLS directives. This approach was based on soliciting self-evaluations from service providers as well as assessments from clients of the services they received. ProVIC also worked with relais communautaires to assess the quality of services, having them visit health centers as clients and anonymously evaluate their experiences. Staff from the PNLS national and provincial laboratories conducted regular quality control assessments in laboratories using dried blood spot and dried tube specimens to assess the reproducibility of results. Depending on the scores obtained by the laboratories, ProVIC offered training to laboratory staff to reinforce their capacity. Additionally, ProVIC built capacity for quality assurance through the aforementioned series of HTC, injection safety, and biomedical waste management trainings.

Sub-IR 1.3: Prevention of mother-to-child transmission of HIV services improved Over the course of the project, ProVIC worked in close collaboration with the MOH/PNLS to promote international best practices in PMTCT within the DRC. ProVIC oriented its comprehensive PMTCT interventions according to the priorities defined in the DRC’s 2012–2017 National Elimination Plan. The three areas below were the focus of the ProVIC PMTCT platform: • Increasing access to and uptake of comprehensive PMTCT/ART services. • Increasing the promotion and uptake of pediatric testing and ART services. • Contributing to the reinforcement of government capacity at all levels to provide comprehensive PMTCT services.

ProVIC provided antiretroviral medications (ARVs) to 3,707 HIV-positive pregnant women to reduce the risk of mother-to-child transmission.

Evolution of PMTCT activities ProVIC initiated PMTCT activities in 2010 at 16 health facilities in the project’s four operating provinces, linked to CCs as part of ProVIC’s initial community-focused model. These facilities were integrated as clinical referral points for PLWHA and OVC as part of the larger network of services offered by ProVIC. ProVIC expanded its coverage of PMTCT interventions with the PMTCT Acceleration Initiative. By the end of FY2012, the project had expanded to support 44 health facilities in the five project provinces. By FY2013, in alignment with the PEPFAR Strategic Pivot toward treatment, ProVIC had integrated comprehensive adult and pediatric treatment services and had expanded to support 103 health facilities. By FY2014, ProVIC had expanded to support 112 health facilities.

As the centerpiece of an integrated HIV care program, increased emphasis was placed on the importance of PMTCT services and improving outcomes along the continuum of care for PLWHA. As part of the effort to increase the promotion and uptake of comprehensive PMTCT services, the ProVIC team prioritized the following areas: • Expansion of program activities to reach 85% PMTCT coverage in project-supported health zones.

20 • Extension of PMTCT activities to new, higher HIV prevalence health zones in order to reach a greater number of HIV-positive pregnant women, families, and individuals with a complete package of PMTCT services.

Results Over the course of five years, ProVIC was able to strengthen linkages between communities and facilities and improve the quality of the continuum of HIV care services provided to women, their partners, and their children. ProVIC worked to scale up HIV testing and treatment services for pregnant women, expanding the offering of antenatal care (ANC) services that included HIV testing and provision of ARVs from 74 health facilities in FY2013 to all 112 ProVIC-supported health facilities in FY2014. Figure 15 shows the increase in the number of pregnant women with known HIV status, and Figure 16 illustrates the continuous increase in the number of known HIV-positive pregnant women who received ARVs from FY2009 through FY2014.

Figure 15. Pregnant women with known HIV status by fiscal year, October 2009–September 2014.

80,000 72,760 70,000

60,000 52,585 Number 50,000 of pregnant 40,000 women 33,014 28,446 30,000

20,000

10,000 6,880

0 FY2010 FY2011 FY2012 FY2013 FY2014

Annual target

Figure 16. Percentage of HIV-positive pregnant women who received ARVs by fiscal year, October 2009–September 2014. 100.00% 84.0% 91.9% 75.0% 78.3% 80.00% 64.5% Percentage of 60.00% HIV-positive pregnant 40.00% women 20.00% on ARVs 0.00% FY2010 FY2011 FY2012 FY2013 FY2014

21 Figure 17 shows an improvement in the PMTCT continuum of care for HIV-positive pregnant and breastfeeding women. From 2012 through 2014,†† there was an increase in the number of women being tested for HIV at ANC and labor and delivery. The percentage of HIV-positive pregnant women who returned to the facility where they were tested to give birth also increased between FY2013 and FY2014, from 12% in FY2013 to 22% in FY2014 (an improvement to a challenge that ProVIC faced in FY2010– FY2012), as did the number of HIV-positive women who initiated treatment for PMTCT. The general improvement across PMTCT indicators demonstrates the strengthening of linkages between communities and facilities to improve the continuum of care for HIV-positive pregnant women. Mentor Mothers (community actors) worked in close collaboration with health care providers at facilities to ensure that HIV-positive mothers were retained in care and treatment programs.

Figure 17. HIV testing and treatment outcomes for pregnant/breastfeeding women, October 2012– September 2014.

1800 1588 1600 1434 1348 1400 1242 1160 1200 1108 1000 Number of women 800 625 607 569 600 346 400 240 275 200 133 18 0 FY 2012 FY 2013 FY 2014

Pregnant women tested HIV+ Pregnant women tested HIV+ at ANC Women tested HIV+ during labor and childbirth HIV+ women receiving ARVs to reduce risk of MTCT HIV+ pregnant women returning to facility for delivery

Figure 18 shows the increase in the percentage of infants born to HIV-positive pregnant women who received an HIV test within 12 months of birth and were started on CTX prophylaxis within two months of birth. The increase in FY2012 is primarily due to trainings and on-site mentorship provided to health care workers and laboratory technicians on sampling for EID. The decrease observed in FY2013 may be due to data collection challenges as well as the addition of a number of new sites (as a result of the PMTCT Acceleration and Strategic Pivot) whose providers needed training and mentorship on EID and tracking exposed infants.

†† ProVIC’s datacard system was set up in FY2012, so some data from FY2010–FY2011 were not collected.

22 Figure 18. Percentage of infants born to HIV-positive pregnant women provided with PMTCT services, October 2009–September 2014.

60.0% 52.4% 50.0%

40.0% 34.7% 34.3% 33.6% 31.7% 30.0%

20.0% 16.0% 11.6% 12.0% 8.8% 10.0% 1.3% 0.0% FY2010 FY2011 FY2012 FY2013 FY2014

Percent of infants who received an HIV test within 12 months of birth Percent of infants who are started on CTX within two months of birth

Counseling, testing, and treatment services were also made available for HIV-positive male partners, who were then able to receive CTX, were assessed for CD4, and received highly active antiretroviral therapy (HAART). As the result of this access to and provision of services, increases were observed in the number of male partners who received testing and counseling (from 1,703 in FY2013 to 6,144 in FY2014) and for those who tested HIV positive (from 78 in FY2013 to 156 in FY2014). In all, 13 male partners were put on HAART in 2013; this number increased to 86 in 2014.‡‡ These results are summarized in the table below.

Table 3. Numbers and percentages of male partners of pregnant/breastfeeding women tested and enrolled in treatment services, October 2012–September 2014. FY2013 FY2014 Pregnant/breastfeeding women tested for HIV 52,585 72,760 Male partners tested for HIV 1,703 6,144 Percentage of male partners tested 3% 8% Male partners who tested HIV positive 78 156 Seropositivity rates of male partners 5% 3% HIV-positive male partners placed on ART 13 86 Percentage of HIV-positive male partners placed on ART 16% 55%

‡‡ Data are available only for FY2013–FY2014; ProVIC did not focus on these activities until FY2013, when the project shifted its focus to treatment as a result of the Strategic Pivot.

23 Figure 19 shows a net decrease in seropositivity rates among male partners of pregnant women who were tested for HIV from October 2012 through September 2014.§§

Figure 19. Seropositivity of male partners, October 2012–September 2014.

5.0% 4.6% 4.5% 4.0% 3.7% 3.5%

Seropositivity 3.0% 2.5% rate 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% FY2012 FY2013 FY2014

Summary of interventions Increasing the number of sites offering PMTCT services within ProVIC-supported health zones As part of the Strategic Pivot guidance, ProVIC was advised to increase coverage (and sites) in health zones already covered by the project and to add strategic new health zones in Katanga and Province Orientale. Following a needs assessment to identify appropriate sites, ProVIC adapted PEPFAR’s strategic recommendations in Q3 of FY2013 and increased PMTCT coverage within existing health zones by partnering with new health facilities with reported higher HIV prevalence as well as higher facility attendance by pregnant women. Scale-up primarily affected three provinces: Katanga, Orientale, and Kinshasa. Table 4 shows the distribution of health facilities across ProVIC’s four operating provinces that were supported in Q3 and Q4 FY2013, following ProVIC’s scale-up.

Table 4. Distribution of ProVIC-supported health facilities, October 2013–March 2014 Province Health zones Hubs Spokes Total health facilities Kinshasa 6 5 10 15 Katanga 12 12 42 54 Orientale 5 5 20 25 Bas-Congo 5 5 13 18 Total 28 27 85 112

To reach targets in health zones with markedly low attendance, ProVIC worked with health zone management teams to introduce an “accompanied advanced strategy.” Similar to the peer-to-peer local capacity development model (further explained in Section D), this strategy sought larger geographic

§§ Data on male partners of HIV-positive pregnant women were not collected before FY2012.

24 coverage to better reach pregnant women and ensure that those women had access to the continuum of care according to national standards.

To facilitate the implementation of activities in the new health facilities and health zones, ProVIC: • Conducted, under the leadership of the PNLS, a large-scale training for health care providers in new sites in the three priority provinces on the national integrated HIV package. Essential components of the training included PITC, PMTCT, ART, family planning, gender-based violence, and care and support. In total, 1,297 providers benefited from the ProVIC-led training. • Provided commodities and additional support as needed. In collaboration with the Supply Chain Management System (SCMS), ProVIC used quarterly inventories of laboratory commodities (HIV and syphilis test kits and laboratory accessories), ARVs (both adult and pediatric), CTX, STI drugs, waste management equipment, contraceptives for family planning, condoms, and data collection tools to ensure that health facilities were regularly supplied with commodities and technical assistance as needed. ProVIC also organized trainings for supply management and laboratory staff to increase their capacity to offer services. In addition, ProVIC signed a cost reimbursable contract with each health facility and health zone for the provision of support such as dried blood spot sample transportation, maternity fees for HIV-positive women, and transportation fees for Mentor Mothers.

Providing a package of comprehensive PMTCT services at ProVIC sites The traditional four pillars of PMTCT are (1) primary HIV prevention; (2) integration of PMTCT and family planning; (3) treatment and prophylaxis during pregnancy and breastfeeding; and (4) ongoing monitoring, treatment, care, and support for women and their families. ProVIC’s approach to the four pillars was addressed within the health facilities with a combination prevention strategy that incorporated both HIV and maternal, newborn, and child health (MNCH) across the continuum of services. This approach was undertaken to maximize access to services for HIV-positive pregnant, delivering, postpartum, and breastfeeding women and their families (a ProVIC Photo: family-centered approach).

ProVIC made a commitment to complete the PMTCT package in hub and spoke sites in accordance with PEPFAR orientations and in alignment with national standards and policies. This integrated package took into account the following services: (1) community activities carried out through sensitization messages provided by community workers to support male partner involvement and to encourage pregnant women to seek early Masi PATH/F. Photo: ANC (in the first quarter of their pregnancy), complete all four Data collection tools provided by ProVIC. ANC visits, and follow up on their children’s under-five care; and (2) health facility activities to reduce mother-to-child transmission of HIV as described below.

Pillar 1—Primary HIV prevention: The ProVIC PMTCT team worked with providers to ensure that during routine ANC sessions, women felt welcomed at health facilities and were provided with comprehensive messaging on HIV, maternal and child health, and sexual and gender-based violence. Providers were mentored to improve the messaging they provided during routine ANC education sessions, including specific messaging on HIV, PMTCT, family planning, sexual and gender-based violence, and the importance of good nutrition, sanitation, and malaria prevention.

Male partner engagement in HTC was encouraged under ProVIC’s PMTCT program. Specifically, ProVIC sent invitation letters to male partners of HIV-positive pregnant women, extended HTC service

25 hours during weekends and holidays to make HTC more accessible to male partners, and encouraged male partners who accompanied their wives during delivery to be tested for HIV. ProVIC also encouraged HIV-positive pregnant and breastfeeding women to have their other children tested for HIV: Mentor Mothers sensitized HIV-positive mothers on the importance of testing their children for HIV and encouraged mothers to bring their other children into a facility to be tested.

Through PITC for pregnant women and their male partners, ProVIC ensured that both HIV-negative and HIV-positive persons benefited from the prevention package for PMTCT. This package included education on consistent and correct condom use and condom negotiation skills, ensuring an adequate supply of condoms and lubricant, and incorporating Prevention with Positives interventions (discussed in sub-IR 2.1), as well as encouraging the testing of couples. The prevention package contributed to preventing HIV infection of women during pregnancy and breastfeeding to decrease the risk of HIV transmission to their infants and/or to their HIV-negative male partners. After clinical services, all tested clients were linked to community organizations according to their HIV status.

Pillar 2—Integration of PMTCT and family planning: Providers used the regular repeated visits for ANC services and HIV care and treatment services as opportunities to provide women and their male partners with family planning counseling and services according to MOH guidelines, thus giving clients the opportunity to select their preferred family planning method. The services included counseling on exclusive breastfeeding for the first six months, the lactational amenorrhea method, and modern contraceptives or provision of safe pregnancy counseling for women living with HIV who wished to have children. ProVIC provided a broad contraceptive method mix, made available through the Association de Santé Familiale (Family Health Association), including male and female condoms, CycleBeads, intrauterine devices, Depo-Provera®, and Jadelle® implants. Family planning counseling encouraged dual protection, which included the provision of condoms and a second form of protection. The majority of HIV-positive women preferred modern contraceptive methods, mainly Jadelle® implants and Depo- Provera®.

During site visits, the ProVIC teams (PMTCT/ART, pediatric, and provincial prevention specialists) provided technical assistance to providers to reinforce the linkages between PMTCT activities and family planning as well as other maternal and child health services. Where family planning services were not yet implemented, providers were encouraged to organize the referrals for pregnant women in need. The providers at faith-based facilities were also encouraged to refer clients to the closest facility where family planning services were available. The referral sites were identified in collaboration with health zone teams and the faith-based sites.

Pillar 3—Provision of ART for pregnant, postpartum, and breastfeeding women and infant prophylaxis: The DRC protocol for HIV-positive women has evolved from single-dose nevirapine to Option A to the introduction of Option B+. ProVIC started the pilot of Option B+ in September of 2013 in six sites in Lubumbashi, Katanga Province. This pillar was strengthened through the introduction in some health facilities of best practices such as (1) prepackaging of a kit containing ARVs, provided to each woman after she tested HIV positive (zidovudine for Option A or TDF/3TC/EFV*** for Option B+); provision of CTX prophylaxis and condoms; (2) adherence counseling, emphasized by Mentor Mothers in areas where the Mentor Mother approach was implemented; (3) a delivery model for integration of ART services within maternal and child health clinical sites, with arrangements for ongoing, high-quality HIV

*** TDF: tenofovir disoproxil fumarate; 3TC: lamivudine; EFV: efavirenz.

26 care and treatment services; (4) encouragement to decentralize the delivery of ART to peripheral health facilities and task-sharing to allow nurses to initiate and maintain ART within the national regulatory framework; and (5) strengthening of linkages between providers and community actors (Mentor Mothers or other peer counselors) to maintain HIV-positive pregnant and breastfeeding women in the ART program to improve retention and adherence and reduce loss to follow-up.

Pillar 4—Ongoing monitoring, treatment, care, and support for women and their families: This complete PMTCT comprehensive package was implemented in all 112 ProVIC-supported sites by 2014. The efforts initiated in Year 4 were maintained and reinforced in Year 5. In addition to the HIV prevention and family planning interventions described previously, the PMTCT program, supported by ProVIC, integrated the provision of essential care elements, including CTX prophylaxis; TB screening and referral for treatment; screening and treatment for opportunistic infections; adherence counseling; prevention and treatment of malaria and syphilis; high- quality ANC and delivery services; nutrition assessment, counseling, and support (NACS); and psychological support through Mentor Mother groups. Additionally, GBV screening and care were provided in the PMTCT setting.

Introducing Option B+ Through the provision of high-quality health facility services, ProVIC’s care and treatment activities promoted quality of life for HIV- positive pregnant and breastfeeding women,

their partners, their children, key populations, young people at risk, and patients identified through testing. In alignment with the World Photo: ProVIC Photo: Health Organization’s (WHO) new Mother and her twins, Mvuzi Health Reference Center. recommendations, ProVIC contributed to the introduction of Option B+ (lifelong ART for all HIV-positive pregnant women) in the DRC by supporting six pilot sites as part of the PNLS/United Nations Children’s Fund (UNICEF) rollout, and further expanded Option B+ in Katanga in 2014, with plans to roll out Option B+ to all sites in FY2015.

Improving the quality of services offered by introducing new approaches The ProVIC PMTCT team provided tailored technical assistance at all levels (site, health zone, provincial) to ensure up-to-date training on integrated PMTCT services, and, over the course of five years, introduced various approaches to ensure the high quality of those services. ProVIC participated in national-level MOH and PNLS working groups to provide expertise on PMTCT and treatment policies and guidelines as they were developed and established by the government. At the provincial level, ProVIC supported health zone teams to improve site supervision, and at the health facility level, ProVIC provided health care workers with training and supportive supervision on HTC, PMTCT, and treatment services to improve the quality of services provided to patients. ProVIC also provided technical assistance

27 around data collection and reporting to ensure that patients were being closely tracked and results accurately reported.

Performance-based financing In collaboration with both the DRC government (the MOH Secretary General) and USAID, ProVIC launched its first performance-based financing (PBF) for the PMTCT pilot at Kikimi Hospital Center in Kinshasa at the end of Q2 Year 4. In contrast to ProVIC’s traditional way of providing financing (fixed monthly budgets or direct support based on identified need), the PBF mechanism budget was determined (up to a pre-set maximum) based on the results achieved.

Table 5 shows the 13 indicators used to measure performance and the achievements made from April 2013 to April 2014 at ProVIC-supported Kikimi Health Center. In all, six of the 13 contractual indicators reached greater than 100% achievement; six of the 13 indicators saw between 80% and 100% achievement; and one indicator achieved less than 60% of the target.

Table 5. Completion of PBF contractual indicators at Kikimi Health Center, April 2013–April 2014. Baseline Contractual indicator Target Result Achievement (2011) HIV-exposed infants who received ARV prophylaxis (nevirapine) 7 19 23 121% HIV-positive pregnant women who gave birth at a maternity 6 23 27 117% hospital Male partners who were tested for HIV and received their results 115 395 461 117% Family members who were tested for HIV and received their 19 115 130 113% results HIV-exposed infants breastfed at six weeks 4 22 24 109% Women (pregnant and breastfeeding) who were tested for HIV 202 979 1,057 108% and received their results HIV-exposed infants who received CTX 2 16 16 100% HIV-positive pregnant women assessed for CD4 6 27 26 96% HIV-positive mothers who accepted a family planning method 1 29 27 93% plus condoms HIV-exposed infants who received early infant HIV diagnosis 4 26 24 92% (were tested) HIV-exposed infants who were tested at 18 months 3 14 12 86% HIV-positive pregnant women who received ART 8 32 26 81% Monthly reports analyzed and consolidated with the health zone 0 12 7 58% and transmitted in time

An MOH-led evaluation of this approach found that despite the relatively short duration of the PBF implementation, the Kikimi hospital community found (1) increases in certain performance indicators, (2) convenience in the existence of a single fund instead of several pools/sources, (3) strengthened collaboration between health facility staff, (4) more motivation among the health team and increased team cohesion, (5) improvements in the completion of patient tracking tools and registers, and (6) increased patient attendance.

28 ProVIC faced two major challenges implementing PBF. First, the PBF model piloted in Kikimi Health Center was focused only on PMTCT interventions, and this created a difference between providers in the hospital. To address this, ProVIC and the MOH recommended the hospital use one of the PBF tools that allocates funds to all workers in the hospital using a formula that gave PMTCT providers more funding than the others. The second one concerned the involvement of the health zone team. We noted in the table that the indicator concerning the submission of monthly reporting to the health zone was weak (58% achievement); the underperformance in this particular indicator was partially due to the transfer of the head of the health zone to another project, which hindered adequate follow-up efforts on the health zone side. ProVIC and the MOH worked with his successor, but he was not as motivated as he had not been involved from the start.

The MOH recognized the Kikimi PBF pilot as being of good quality, with fidelity to PBF norms, and as a model that could help improve the quality of PMTCT services provided to clients. The MOH recommended that the approach be extended to other units within Kikimi Health Center as well as to other health centers across different health areas. In addition, the MOH brought World Bank interns to Kikimi Health Center to learn how to conduct good-quality PBF. The World Bank conducted an assessment focusing on the quality of services among six health facilities in Ndjili Health District. Kikimi was found to have the highest quality of services in the health district and was allocated additional funds by the World Bank as a result.

The MOH recognized the PBF model as one that can help improve the quality of PMTCT services provided to clients. Included in their evaluation are recommendations to extend the approach both to other units within Kikimi Health Center as well as to other health centers and across various health areas.

Quality assurance/quality improvement approach With technical support from University Research Co., LLC, ProVIC selected 14 maternity hospitals (six in Kinshasa, six in Katanga, and two in Province Orientale) in which to pilot QA/QI activities following their “Improvement Collaboratives” approach. Pilot activities began in four maternity hospitals in Kinshasa in January 2013. ProVIC organized orientation sessions for government partners and trained 69 multidisciplinary coaches to ensure ongoing coaching visits to the targeted maternity hospitals.

After three months, ProVIC held a learning workshop with QA/QI health facility providers to exchange information about the strategies they used to improve their performance. ProVIC noted that participating health facilities increased all the indicators tracked in the pilot, noting specifically an improvement for one of ProVIC’s weak indicators related to male partner testing. Figure 20 shows the trends of male partner testing comparing five sites implementing the QA/QI approach with nine sites not implementing the approach in Kinshasa.

29 Figure 20. Male partners of HIV-positive pregnant women tested, October 2012–September 2013.

350 300 250 Number of 200 male partners 150 tested 100 50 0

QA/QI Sites Non- QA/QI Sites

In general, ProVIC did not face many challenges introducing the QA/QI approach and the model was a very practical one. One challenge noted concerns the involvement of the health zone management teams and the large burden placed on them under this approach, given that these teams are contributing to a large number of activities for the number of implementing partners. One tactic taken by ProVIC to reduce the burden and increase the involvement of health zone management teams was to reduce the number of coaching visits from twice a month to once a month after health care providers were confident with their duties (typically three months after start-up).

Increasing linkages between communities and clinics In collaboration with the MOH and other partners, ProVIC developed an integrated model to reinforce linkages between clinic and community activities and to provide ART to all pregnant and breastfeeding women. The goal of this model was to reduce loss to follow-up and to reinforce the collaboration between community and clinic actors to improve prevention and care outcomes. The model describes the expected way to further integrate MNCH, PMTCT, and ART service delivery with community activities to improve the continuum of response for PLWHA. While community actors oriented individuals for HIV testing at the health facilities, providers received clients at each entry point. Following PITC, providers offered the appropriate package of services and relinked the patients to community organizations: HIV- negative people were encouraged to join community-based associations providing prevention and HIV risk reduction messages; HIV-positive persons were encouraged to join the group with which they most identified (e.g., Mentor Mothers).

Increasing the promotion and uptake of pediatric testing and counseling and provision of ART Retaining mother-infant pairs in PMTCT and HIV care services is a significant challenge in the DRC. Social and economic barriers such as stigma and lack of money for transportation often cause HIV- positive mothers to skip services or go to new sites where they are unknown, making it difficult for programs to coordinate and provide optimal care. To better retain mother-infant pairs in PMTCT and HIV care services, ProVIC instructed CCs to focus the messaging provided to HIV-positive pregnant women on PMTCT and early infant HIV diagnosis (EID) and used social workers and community health workers to facilitate access to nutritional and psychosocial support. Eligible pregnant women were also

30 accompanied by a social worker to HIV clinics for testing, and HIV-positive women who had given birth were referred and accompanied by a social worker to a clinic to have their child tested for HIV.

To monitor these complex issues and course correct as needed based on findings, ProVIC established indicators that could act as a proxy for mother-infant pairs. Indicators such as infants on CTX within two months were used to track enrollment in care and treatment at ProVIC-supported sites. As depicted in Figure 21, progressive improvements were noted in EID, with an observed increase in the number of HIV-exposed infants tested for HIV within 12 months of birth. The number of infants placed on CTX within two months of birth also increased over time, from 71 infants in FY2011 to 243 infants in FY2014.†††

Figure 21. Progress on HIV-exposed infant identification and treatment, October 2009–September 2014.

600 524 474 500

381 400

300 252 243 188 200 121 71 100 18 2 0 FY2010 FY2011 FY2012 FY2013 FY2014

Infants born to HIV+ mothers who received an HIV test within 12 months of birth Infants born to HIV+ mothers placed on CTX within two months of birth

ProVIC was a leader in the DRC in strengthening systems for EID and linking exposed infants to care and treatment. Throughout the life of the project, the ProVIC team focused on increasing the promotion and uptake of pediatric testing and counseling and improving follow-up of mother-infant pairs. ProVIC worked hard to ensure effective referrals of infected infants to treatment and initiation of HIV-exposed infants on CTX. ProVIC was one of the first programs in the DRC to create a network for collecting and transporting samples and returning EID results to families. Supporting this network, ProVIC strengthened referral systems with phone calls to mothers and a system to monitor successful referrals. As a result, more exposed infants in ProVIC’s target provinces continued to be identified earlier using polymerase chain reaction (PCR) DNA analysis for EID at six weeks of age. Once identified as HIV positive, infants were referred to either a Global Fund or Clinton Foundation facility where drugs for pediatric treatment

††† Data from FY2010–FY2011 are incomplete as ProVIC’s datacard collection system had not yet been set up.

31 were available. As of September 2014, 298 children (up to 14 years of age) were enrolled in ART—the table below provides a breakdown of children in ProVIC’s active ART cohort.‡‡‡

Table 6. Number of HIV-positive children on ART by sex. Age group Female Male TOTAL 0–1 year old 24 14 38 1–4 years old 53 30 83 5–9 years old 42 52 94 10–14 years old 38 45 83 TOTAL 298

Intermediate Result 2: Care, support, and treatment for people living with HIV/AIDS and orphans and vulnerable children improved in target areas

Sub-IR 2.1: Care and support services strengthened ProVIC’s care and support component (Table 7) helped to improve the quality of life for PLWHA in the DRC. Care and support activities were built around the following objectives: • Early identification of people infected with HIV, and then linking them to care and retaining them in care. • Reduction of HIV-related mortality and morbidity. • Improvement in quality of life.

Table 7. ProVIC’s care and support activities. Care Support Palliative home care Psychological support to ensure retention in care Provision of CTX prophylaxis Social and spiritual support Systematic TB screening of all PLWHA Legal assistance to combat stigma and discrimination Management of malnutrition Nutritional support Medical referral of PLWHA patients Positive prevention CD4 count and biological monitoring of PLWHA on Economic empowerment through IGAs ARV regimens

‡‡‡ Data on ProVIC’s ART cohort is from Tier.net.

32 In collaboration with local partners, ProVIC provided health care and support services to PLWHA from 49 CCs across 112 health facilities in the provinces of Katanga, Kinshasa, Sud Kivu, Bas-Congo, and Orientale.

Evolution of care and support activities During Phase 1 of the project, care and support activities were offered at the community level through CCs, with referrals to local health facilities for further treatment and care. ProVIC organized PLWHA into self-help groups to provide a forum for receipt of support, to identify care needs, and to be referred to appropriate service providers for further care and support. Self-help groups were also used to disseminate information on topics relevant to PLWHA, such as the importance and side effects of CTX, personal hygiene, nutritional education, prevention of opportunistic infections, TB, STIs, and positive prevention. To improve adherence and retention in care, community volunteers also conducted home visits to individuals who could not participate in self-help group meetings.

As ProVIC entered Phase 2, most care and support activities shifted to PMTCT sites to better support the continuum of care for pregnant and breastfeeding HIV-positive women, their male partners and children, at-risk youth, key populations, and other clients identified through PITC. Health facilities, while delivering specific clinical services, also worked closely with neighboring communities to ensure the provision of a package of prevention, treatment, and support services through integrated PMTCT self- help groups. Some community-based self-help groups continued meetings and activities in Phase 2, although meetings occurred less frequently due to the decrease in funding for community-based activities.

In Phase 3, ProVIC focused its care and support efforts on improving access to and retention in a wide range of preventive and treatment services related to HIV/AIDS and health. Collaboration between communities and health facilities via Mentor Mothers reinforced adherence to treatment. ProVIC’s USAID partner Livelihood and Food Security Technical Assistance (LIFT) provided technical assistance in establishing a volunteer savings and loan association model that was introduced to strengthen links between communities and clinical services and contribute to community empowerment and resilience. A key element of the post-Pivot strategy was the development of facility-based self-help groups targeting pregnant women and other family members, which had linkages to community self-help groups. These linkages between facility- and community-based groups helped to facilitate referrals and counter-referrals between service providers and communities and improve retention in treatment, while also promoting access to an integrated package of care services.

Results During the last year of the project (FY2014), 22,653 PLWHA (adults and children) received at least one care service and 13,351 PLWHA (adults and children) received at least one clinical service— these represent ProVIC’s final cohort of PLWHA receiving clinical and care services. Figures 22 and 23 show the number of individuals reached with care ProVIC Photo: and support and clinical services annually, A doctor facilitates a PLWHA self-help group meeting in Kingasani respectively. Figure 24 compares the Champion Community, Kinshasa.

33 number of OVC and PLWHA who received care and support services in each year from October 2009 through September 2014. More women than men received services, both clinical and care and support, across all fiscal years.

Figure 22. Eligible adults and children provided with at least one care and support service by sex, October 2009–September 2014.

25,000

20,000 8,119 7,668 7,684 15,000 8,339 Number of eligible adults 5,918 and children 10,000

14,534 12,642 13,128 11,185 5,000 9,642

0 FY2010 FY2011 FY2012 FY2013 FY2014 Female Male Annual target

Figure 23. PLWHA who received a minimum of one care service, October 2009–September 2014.

16,000 14,229 14,000 12,618 11,695 12,000 10,686

10,000 8,615 8,299 8,424 10,126 Number of 8,000 PLWHA 6,906

6,000 7,261

4,000

2,000

0 FY2010 FY2011 FY2012 FY2013 FY2014 Adult Children

34 Figure 24. HIV-positive adults and children who received at least one clinical service by sex, October 2009–September 2014.

16,000

14,000

12,000 Number 3,826 of 10,000 HIV-positive 3,018 adults 8,000 and 2,049 6,000 children 1,847 9,525 4,000 7,439 1,113 5,633 2,000 4,635 1,958 0 FY2010 FY2011 FY2012 FY2013 FY2014

Female Male Annual target

ProVIC provided CTX prophylaxis to 7,951 PLWHA across four provinces in FY2014. About 73% of those who received CTX in FY2014 were women, which is consistent with the higher rate of HIV among DRC women. Figure 25 shows the number of individuals who received CTX by year.

Figure 25. PLWHA who received CTX by fiscal year, October 2009–September 2014.§§§

9,000 8,206 7,953 7,951 8,000

7,000 6,144 6,000

5,000 Number of PLWHA 4,000

3,000

2,000 1,552

1,000

0 FY2010 FY2011 FY2012 FY2013 FY2014 Annual target

§§§ ProVIC did not collect sex-disaggregated data in FY2010.

35 Figure 26 highlights results of ProVIC’s efforts to systematize screening for TB among PLWHA, with a significant increase in the number of PLWHA who were screened for TB from FY2012 until the end of the project.

Figure 26. Number of HIV-positive patients screened for TB, October 2011–September 2014.

12,000 10,583 10,000 8,375 Number of 8,000 individuals 6,000 screened for TB 4,000

2,000 397 0 FY2012 FY2013 FY2014

As illustrated in Figure 27, 2,099 PLWHA received the Prevention with Positives package at either the community or facility setting from October 2013 through September 2014.**** The decrease in PLWHA provided with a package of prevention services in a community setting from FY2011 through FY2014 illustrates ProVIC’s increasing shift toward offering services at health facilities instead of at the community level following the Strategic Pivot.

Figure 27. PLWHA who received a package of positive prevention services at community or facility settings, October 2010–September 2014.

12,000

10,000 10,057

8,000

Number of 6,000 PLWHA 4,000 3,106 3,051

2,000 1,120 592 606 0 124 979 FY2011 FY2012 FY2013 FY2014

Health facilities Communities

**** ProVIC did not collect disaggregated data on this indicator in FY2010.

36 Summary of interventions Disease prevention with CTX prophylaxis ProVIC began distributing CTX to PLWHA in 2011. CTX was distributed at the community level through self- help group meetings and home visits for PLWHA who had disclosed their status, and at the facility level during clinic visits. In Year 4, following the Strategic Pivot, community-level distribution was stopped. ProVIC’s

NGO grantees also collaborated with health facilities to ProVIC ensure that CTX was offered to all PLWHA clients who had previously obtained CTX at the community level, Photo: thus ensuring ongoing provision of CTX treatment for all Certification ceremony for community agents who PLWHA. participated in HIV/TB co-infection training.

TB screening and referral for diagnosis and treatment ProVIC’s TB screening and referral activities grew consistently throughout implementation, adapting to the project’s technical shift toward treatment and facility-based services. The project aligned its TB services to PEPFAR guidelines and focused on ensuring that all PLWHA were screened for TB. In 2013 and 2014, efforts were made to systematize monthly TB screenings for all PLWHA at both the health facility and community levels through use of a TB screening questionnaire that health care providers and community workers completed during clinic or home visits. Suspected TB cases were then referred to health centers for diagnosis and treatment. Health care providers and community volunteers also screened PLWHA for TB symptoms during medical consultations, home visits, and self-help group meetings. Individuals found to be TB positive were screened for HIV and referred to prevention, care, and support services.

To further strengthen the early detection and treatment of TB, PATH piloted “community hubs” to better educate communities on TB prevention and the provision of HIV/TB co-infection care and support services. With financial support and technical assistance on the management of HIV and TB co-infection provided by the TB 2015 project, 40 community agents were trained as trainers to provide training to other community members on TB prevention, referrals of suspected TB cases to clinics for diagnosis, home-based support, and TB monitoring.

Nutritional support to PLWHA and OVC ProVIC’s provision of nutritional support to PLWHA and OVC evolved during project implementation, from distribution of food to being part of the comprehensive package of care services offered to PLWHA and OVC. The range of strategies used by ProVIC to provide nutritional support included the distribution of food “kits” to the most vulnerable households, the organization of community meals at self-help group meetings, and the promotion of economic empowerment through agro-pastoral activities and income- generating projects.

In 2012, in collaboration with the Food and Nutrition Technical Assistance II Project (FANTA II) and LIFT, ProVIC focused on the prevention and treatment of malnutrition by targeting pregnant and breastfeeding women and malnourished children. Nutritional support provided by ProVIC followed the NACS approach, and suspected cases of malnutrition were systematically referred to Ambulatory Treatment Nutritional Units and Intensive Treatment Nutritional Units, where PLWHA, OVC, and pregnant and breastfeeding women could access ready-to-use therapeutic food. In 2013 and 2014, ProVIC worked closely with FANTA II to reinforce the NACS approach among health care providers in ProVIC-

37 supported facilities in Kinshasa and Katanga Provinces, and project staff developed a nutrition status monitoring sheet to help care providers better assess the impact of nutrition interventions on PLWHA.

Photos: ProVIC Photos: Distribution of food kits to PLWHA and OVC in Katanga Province.

ProVIC also contributed to the development of national protocols and tools around nutritional assistance for PLWHA. It supported the finalization of the National Protocol for the Nutritional Care of PLWHA, which provided a set of standards and best practices for assessing the nutritional needs of PLWHA and referring cases of moderate and acute malnutrition to care services. Based on this protocol, ProVIC produced a guide and job aides on nutrition for PLWHA for use during home visits and self-help group meetings. These guides bolstered the capacity of community volunteers and caregivers to provide appropriate nutritional care.

Child immunization Monitoring children born to HIV-positive mothers to ensure adherence to immunization schedules was an essential component of ProVIC’s care and support package. During maternal medical consultations, service providers counseled HIV-positive mothers on the importance of childhood immunizations and provided them with information on accessing immunization services, with the goal of minimizing the number of children lost to follow-up. Specific services included: • Raising awareness on the importance of vaccinations during medical appointments and caregiver self- help group meetings. • Monitoring vaccination compliance during pre- school pediatric appointments. • Actively identifying children lost to follow-up by calling caregivers and visiting homes to remind and encourage parents to adhere to vaccination schedules. • Ensuring participation of children in government- sponsored vaccination campaigns.

Prevention with Positives package Under ProVIC, PLWHA received a package of positive prevention services intended to help them live Photo: ProVIC Photo: positively and reduce the transmission of HIV. These A nutritionist prepares a nutritional food kit for services were initially provided at the community level malnourished PLWHA in Kinshasa.

38 through self-help group meetings and Improving quality of life and nutrition outcomes home visits but were transitioned to health for PLWHA through income-generating activities facilities following the Strategic Pivot. ProVIC, through its NGO partners, worked with self-help ProVIC’s positive prevention package groups to carry out economic strengthening activities to consisted of six essential services available improve the financial stability, quality of life, and nutritional in health facilities and communities: status of PLWHA. Market research was used to identify the most lucrative IGAs for self-help groups, and members • Assessment of sexual activities, received microcredit loans and training to carry out their distribution of condoms, and advice on chosen IGA. IGAs were monitored by ProVIC’s NGO partners reducing risky behaviors. and members of the local CCSCs to evaluate the success of • Testing of partners of PLWHA. the IGAs and address problems. Categories of IGAs funded by ProVIC included: • Screening for suspected STI cases and referrals to clinics for STI testing and • Community gardens growing manioc, beans, and treatment. groundnuts. • Provision of family planning services • Beauty salons. and referrals. • Refreshment stands.

• Assessment of medication adherence • Sewing school bags, handbags, and table linen. and referrals to specialized adherence Raising livestock. services. •

• Referrals of PLWHA to community- ProVIC also piloted village savings and loan associations based programs, such as home care, (VSLAs) to support PLWHA income generation by building the self-help groups, post-test clubs, and organizational and economic capacity of self-help groups and additional support services. CCSC members to seek solutions to economic instability within their communities. In 2011 and 2012 alone, 741 Improving the quality of life of PLWHA PLWHA received microcredit loans and training on managing ProVIC worked to ensure that PLWHA IGAs, and by 2013, 856 PLWHA had formed 32 VSLAs. received appropriate psychological, social, and spiritual support to promote better integration in society, combat stigma and discrimination, and live with dignity. Psychosocial support was provided through self-help groups, the Mentor Mother approach, home-based visits, IGAs, and legal aid.

Self-help groups: ProVIC established 162 self-help groups for PLWHA over the life of the project. The purpose of these groups was to create a space within which

PLWHA could address their own care and ProVIC Photo: support needs, learn to become A community pharmacy (IGA) for PLWHA in independent, and discuss topics relevant to Kasumbalesa, Katanga. their interests and needs. A PLWHA self- help group typically consisted of about 25 people. These groups were often created through CCs, although facility-based groups were also established. The self-help groups provided an environment in which PLWHA could share their

39 experiences with HIV and health and gain a sense of empowerment. These groups helped to improve the lives of PLWHA in a number of ways:†††† • Establishment of peer savings accounts to address livelihood problems. • Creation of peer exchanges among PLWHA on issues pertaining to positive living, positive prevention, palliative care, reproductive health, and other social and health issues that affect the community. • Provision of high-quality ARV care through health education. • Greater resources for the provision of psychological and spiritual support for PLWHA. • Improved bonds and relationships among PLWHA. • Identification of patients lost to follow-up, especially in finding patients lost to follow-up. • Reduction of negative perceptions of HIV/AIDS.

Mentor Mother approach: ProVIC adopted the Mentor Mother approach to improve the retention and adherence of mother-baby pairs in the PMTCT platform. A Mentor Mother is an HIV-positive mother who has successfully progressed through the PMTCT platform. She receives training on the Mentor Mother approach and is integrated into facility-based support services to sensitize, provide support for, and empower pregnant women and new mothers. Typical activities undertaken by a Mentor Mother include: • Facilitating group talks on topics related to PMTCT and HIV education. • Providing high-quality psychosocial support and counseling services to HIV-positive women and their families. • Referring mother-child pairs to PMTCT, maternal and child health, and other health services in collaboration with community health workers and facility service providers. • Ensuring the adherence of HIV-positive women and their families to PMTCT services. • Following up with clients who missed clinic visits for PMTCT services. • Encouraging male partners to seek health care with their female partners.

Photo: ProVIC Photo: Photo: ProVIC Photo: A care and support specialist with a Mentor Mother in A Mentor Mother sensitizes a male partner at a Kisangani, Province Orientale. health center in Kisangani, Province Orientale.

†††† Based on observations and qualitative information reported by PLWHA in self-help groups.

40 ProVIC conducted a limited qualitative assessment on the Mentor Mother approach in Kisangani from March to October 2013. The assessment followed the participation of 16 HIV-positive pregnant women in Mentor Mother activities to assess the potential value of this approach to ensure adherence to care and support programs. The assessment indicated that the Mentor Mother approach was associated with improvements in adherence of HIV-positive women in support activities and with increased involvement of male partners of pregnant women, as noted in the figure below.‡‡‡‡ Mentor Mother activities were also associated with helping identify patients lost to follow-up and re-engaging them in care.

Figure 28. Participation of HIV-positive pregnant women in Kisangani in PMTCT interventions, March–October 2013. 17

16 16 16 16

Number of 15 individuals 14 14

13 HIV-positive women HIV-positive women HIV-positive women Male partner tested who received who participated in who shared for HIV psychosocial support self-help groups serological status with male partner

Home visits: Home visits were done in all 49 CCs by social workers, community volunteers, and Mentor Mothers. Targeted home visits were organized by NGO grantees and enabled the project to reach out to PLWHA and their households to identify and retain patients lost to follow-up; monitor the status of PLWHA; provide counseling on pertinent health issues in addition to psychosocial, spiritual, and nutritional support; and provide palliative care to sick PLWHA.

Legal aid and rights: ProVIC engaged with local legal advisers and human rights lawyers to provide support to PLWHA and OVC facing legal issues, such as rejection by family, expropriation of assets, conflicts over land ownership and inheritance issues, unfair workplace dismissals, rape and sexual violence, and stigmatization. ProVIC collaborated with the National Centre for Solidarity in Kinshasa, and similar networks in other provinces, to better address the rights of PLWHA. As a result of these collaborations, many covert issues were identified, particularly issues related to child abuse and sexual violence that were not previously revealed. Through the support of ProVIC and legal networks, solutions to some of these issues were identified that upheld the rights of PLWHA, OVC, and their families. These

‡‡‡‡ Please note that an evaluation of the Mentor Mother approach involving a larger cohort of ProVIC-supported facilities is currently underway, which will provide more comprehensive data to determine the impact of the approach. The results of this evaluation will be shared with USAID and the PNLS, once completed.

41 positive experiences also helped PLWHA and OVC gain confidence to report cases of abuse and violence without fear of rejection by the community.

Sub-IR 2.2: Care and support for orphans and vulnerable children strengthened Figure 29. Key areas of care and support for As shown in Figure 29, ProVIC’s care and support OVC. services for OVC focused on health and nutrition interventions, support for education Education and and vocational training, psychosocial support, vocational economic strengthening, and legal aid. The training project aligned OVC interventions and approaches with PEPFAR guidance on OVC, Health and the National Strategic Plan for HIV/AIDS, and Legal aid the National OVC Action Plan for 2010–2014. Orphans nutrition and ProVIC supported an average of 10,232 OVC vulnerable each year with at least one care service. The children Results section below provides detailed information on services provided.

Evolution of activities for orphans and Economic Psychosocial strengthening support vulnerable children ProVIC provided services to OVC from October 2009 to March 2014, when USAID discontinued the provision of OVC services under ProVIC. In the first two phases of the project, providing holistic care and support services to OVC was a critical component of ProVIC’s integrated response to HIV/AIDS under the CC approach. Following the Strategic Pivot in the third phase of the project, ProVIC’s care and support activities for PLWHA and OVC at the community level were discontinued, although some clinical care and support continued based out of health facilities, with a focus on TB and nutrition screening and provision of CTX. The provision of educational support to OVC remained a community-based intervention, led primarily by a ProVIC NGO grantee, Caritas Congo. However, educational support to OVC ended in March 2014, when ProVIC stopped providing support to NGO partners for community-level interventions, due to the project’s focus on health facilities under the Strategic Pivot.

CCs and community workers identified OVC and then linked them to needed health, nutrition, education, and psychosocial services in coordination with the Ministère des Affaires Sociales (MINAS, Ministry of Social Affairs, Humanitarian Action and National Solidarity) and other essential actors, such as Catholic and Protestant churches and Caritas Congo, a local NGO. Another cornerstone of ProVIC’s OVC approach was the provision of psychosocial and emotional support through C2C clubs, which encouraged children and youth to play an active role in the promotion of their own health and well-being in addition to the well-being of their peers, families, and communities.

Variability in results achieved across fiscal years was due to multiple factors, including: • The initial transfer of OVC to ProVIC included many children who were no longer eligible for services and graduated from the program over time.

42 • Support for OVC in Sud Kivu and Bas-Congo concluded in 2013 as ProVIC decreased or stopped operations. • OVC eligibility criteria were revised in Year 4 to support under- and malnourished OVC.

Results The project built on proven interventions and introduced innovations to support OVC who transitioned to ProVIC from previous USAID projects as well as OVC enrolled during the life of the project. Figure 30 shows the number of eligible OVC reached with at least one care and support service over 4.5 years.

Figure 30. Number of eligible children (younger than 18 years) provided with at least one care service by year, October 2009–March 2014.

14,000 12,618 11,695 12,000 10,126 10,000 8,299 8,424 Number of 8,000 children 6,000

4,000

2,000

0 FY2010 FY2011 FY2012 FY2013 FY2014 (Q1/Q2)

ProVIC worked with several schools and vocational training centers in Katanga, Bas-Congo, Kinshasa, and Sud Kivu Provinces and the city of Kisangani to provide education and vocational training to OVC. The number of OVC who received educational support increased in FY2013 and FY2014 (Figure 31) because of ProVIC’s new partnership with Caritas Congo, the primary implementing partner responsible for providing education and vocational support to OVC in Kinshasa, Katanga, and Bas-Congo.

Figure 31. Number of OVC who received educational or vocational training support per year, October 2009–March 2014.

6,000 4,868 5,000

4,000 Number 3,296 of OVC 3,000 2,427 2,072 2,000 1,542

1,000

- FY2010 FY2011 FY2012 FY2013 FY2014 Annual target

43 About 62% of OVC who received educational support were attending primary school, and 65% of these children completed their primary education. Girls accounted for 53% of the total number of OVC supported (Figure 32).

Figure 32. Number of OVC who received educational support by sex and by educational level (primary, secondary, and vocational), October 2009–March 2014.

6000

5000

4000 Number of 3000 OVC 2000

1000

0 Primary School Secondary School Vocational Training Female Male

Figure 33 shows the number of OVC who were referred to health facilities for medical care. Results in FY2011 far exceeded the project target because of mobile health consultations and medical check-ups performed at community sites, such as schools and churches. Figure 34 shows the large number of OVC who were provided with psychosocial support each year. For both figures, the decrease in FY2012 may be partly from underreporting due to misunderstanding created by the introduction of a new data collection method, and further decreases are due to programmatic shifts, particularly the Strategic Pivot and decrease in community-level activities, as described earlier in this report.

Figure 33. Number of OVC referred for health services by year, October 2009–March 2014.

7,000 6,398 6,000

5,000

Number 4,000 of OVC 3,000 1,946 1,693 2,000 1,604

1,000 651

0 FY2010 FY2011 FY2012 FY2013 FY2014 (Q1/Q2)

44 Figure 34. Number of OVC who received psychosocial support by year, October 2009–March 2014.

10,000 8,601 9,000 7,965 8,000 6,934 7,223 7,000

Number 6,000 of 5,000 OVC 4,000 3,000 3,327 2,000 1,000 - FY2010 FY2011 FY2012 FY2013 FY2014 (Q1/Q2)

Summary of interventions ProVIC contributed significantly to the national response for OVC. The project’s OVC approach was based on PEPFAR’s 2012 OVC guidance as well as five foundational principles: • Support should be family centered. • Support should be inclusive and friendly. • Help should be based on the needs of each child. • Families and communities need to be engaged through a participatory process that promotes ownership. • Stakeholders in various fields need to be engaged to offer a complete package of services to OVC.

Access to education and vocational training Education and vocational training were a central part of ProVIC’s support to OVC because they provide ProVIC’s engagement and leadership on issues of the knowledge, life skills, and tools OVC need to orphans and vulnerable children fulfill their potential and become independent adults. Under the leadership of MINAS, ProVIC This support was given through the payment of collaborated with other groups providing support school fees using block grants and the provision of to OVC, such as the World Bank (Street Children free primary school education for the most Project), UNICEF, French Cooperation, Save the Children, and the UN Stabilization Mission in the vulnerable children, in accordance with Congolese DRC to better harmonize and coordinate the law. In keeping with PEPFAR guidance, ProVIC’s provision of interventions aimed at OVC. ProVIC education component focused on ensuring that OVC also became an important member of the National with the greatest needs, and girls in particular, OVC Task Force, co-sponsoring workshops with received the support needed to complete primary UNICEF, and led the development of terms of school. The project also focused on transitioning reference for OVC interventions and consensus- girls from primary to secondary school because of building among stakeholders. the increased vulnerability and greater risk of young girls dropping out after primary school. Over 4.5 years, the project implemented a series of activities to overcome barriers impeding access to education and vocational training, including payment of school or

45 vocational training fees for OVC, as well as the distribution of school kits containing uniforms and supplies and vocational kits containing supplies.

Health promotion activities ProVIC supported interventions at the community and health facility levels to improve the overall health and well-being of OVC. A major component of this work was the provision of food and nutritional support, which was largely provided to OVC through the distribution of food and nutrition kits and nutritional counseling given to caregivers and children during C2C and caregiver group meetings. ProVIC-supported NGOs organized community meals for children at C2C meetings. OVC identified as malnourished were referred to Ambulatory Educational discussion with tutors and children in Kabondo Champion Community in Kisangani, Treatment Nutritional Units and Intensive Treatment Province Orientale. Nutritional Units, where they could access therapeutic food.

Community volunteers and social workers led group talks with parents and caregivers on health and child development topics to promote good childcare practices and better address the specific needs of OVC. Topics included common childhood diseases, hygiene and sanitation, abuse and violence against children, and the importance of monitoring children’s educational development. These issues were also discussed by community volunteers during visits to OVC households.

Clinical services for OVC Group of children in a C2C club in Katanga using ProVIC provided clinical services for all children of the role play. project’s PLWHA beneficiaries, regardless of the child’s HIV status. Children who were HIV positive were placed on ART, and those who tested negative were offered clinical care at ProVIC-support health facilities to address health issues such as malaria, diarrhea, and pneumonia—the three most common causes of mortality in children younger than 5 years in the DRC. Over time, ProVIC sought more integrated and sustainable approaches for households to provide needed health services for OVC. One strategy used in Kinshasa was for Tailoring workshop for orphans and vulnerable ProVIC to cover fees to enroll 427 OVC in a health children in Matadi, Bas-Congo. insurance plan, MUSEKIN. (This strategy could not be used in other ProVIC provinces because of the lack of viable health insurance programs.) Consistent with the project’s shift to treatment and clinical care, the quality of medical care for OVC improved in Year 5, and the provision of medication to OVC was systematized by establishing contracts with medical facilities. USAID also requested that ProVIC support the clinical care of OVC beneficiaries from projects funded by the US Centers for Disease

46 Control and Prevention (CDC) and Department of Defense, and these OVC were linked to ProVIC- supported health facilities and enrolled in health insurance plans, where available.

Psychosocial support and C2C clubs Psychosocial support to OVC was largely provided through the C2C approach, a peer support method that encourages children to actively participate in the promotion of health and community development and seek solutions to community problems. Through this approach, ProVIC sought to address the inequities that negatively affect the quality and level of services provided to OVC and to better respond to the specific needs and issues facing OVC in the DRC. The C2C approach was implemented through the creation of clubs, where children were able to participate in discussions about their needs and solve ProVIC Photo: identified issues. Each C2C club led assessments to identify common problems and issues within the community, suggested solutions to address those problems, and developed an action plan to implement the selected solution(s). Activities undertaken by C2C clubs included counseling parents and caregivers on water purification, purchasing mosquito nets with insecticide to combat malaria, and lobbying a local authority to close a Ciné-Vidéo that projected pornographic films, which the children believed promoted risky sexual behavior and threats to children. The focus group/club setting also allowed for easier provision of services for OVC, such as nutritional support and general health screenings.

Information on health (including topics such as malaria, typhoid, intestinal infections, and handwashing), child protection, nutrition, and other issues related to general well-being were presented to OVC during these meetings. Counseling for parents and caregivers on how to support children was also provided during home visits, community education talks, and recreational days for children.

ProVIC Photo: Photo: ProVIC Photo:

Building blocks of support for orphans and vulnerable children: child protection ProVIC promoted child rights by providing counseling to parents and caregivers on the importance of obtaining birth certificates for children and providing legal assistance to OVC. Children enrolled in C2C groups, parents, and caregivers were also sensitized on child rights, child abuse, and methods to combat corporal punishment, violence, bullying, and intimidation.

Photo: PATH/Felix Masi PATH/Felix Photo: To ensure compliance with PEPFAR and international norms and recommendations, in July 2011, ProVIC intensified its child protection efforts by training partner NGOs and local authorities from the Ministry of Social Affairs on child protection. This training served to strengthen, develop, and enact child protection guidelines to prevent the occurrence of and ensure adequate response to child abuse and exploitation. ProVIC also assisted in drafting child protection policies for all grantees, based on the DRC’s Act on the Protection of the Child. These child protection measures took effect by 2012.

47 Sub-IR 2.3: HIV treatment improved in target areas To ensure effective follow-up of patients on treatment, ProVIC provided a high-quality package of services to ensure that standards of care were consistent with the DRC government’s national guidelines on ART. These services included the integration of prevention (including Prevention with Positives) into care and treatment programs and the provision of comprehensive clinical care, including CTX prophylaxis, CD4 count, HIV treatment, promotion of adherence, screening and management of STIs, screening and referral for TB diagnosis and treatment, management of opportunistic infections, access to appropriate laboratory services, and comprehensive HIV support services and management of ART side effects.

By the end of FY2014, supported an active cohort of 4,209 individuals on ART.

Evolution of HIV treatment activities Sub-IR 2.3 was added in FY2013, when ProVIC expanded its care interventions and supported lifelong ARV treatment for all PLWHA identified in the program, with a focus on the continuum of prevention, care, and treatment services for adults and infants. With PEPFAR’s Strategic Pivot, care and lifelong ART were expanded to include all eligible PLWHA, targeting families of pregnant women, key populations, inpatients, patients with STIs, TB patients, and malnourished individuals.

In FY2013, the PNLS began piloting Option B+ at 17 PMTCT sites in Katanga. At this time, WHO clinical stage 3 or 4 or a CD4 count of ≤350 remained the same for all other categories of adult clients and children more than 2 years old in the program. In the last quarter of FY2014, all ART sites referred to the updated DRC guidelines to enroll patients on HAART, particularly all pregnant women, children younger than 5 years identified as HIV positive, and other patients with a CD4 count of ≤500.

Results ProVIC provided treatment services in Years 4 and 5 for eligible PLWHA in accordance with the DRC’s national protocol.

PITC was offered at different entry points to maximize access to care and treatment services for inpatients, STIs, TB, and malnourished patients, as well as for key populations. For PLWHA newly enrolled in the program, the CD4 count was done at the same site where they were identified or where the sample was transferred.

CD4 testing was strengthened for HIV-positive clients at all entry points from FY2012 (when only 70 pregnant women received CD4 counts) through FY2014 (when 1,224 pregnant women received CD4 counts). More clients were reached in 2014 by expanding the approach from targeting only pregnant and breastfeeding women and male partners to an approach that used other, non-PMTCT entry points for identification (Figure 35).

48 Figure 35. Number of PLWHA who received CD4 testing, October 2011–September 2014.

3,000 2,478 2,500

Number 2,000 of 1,500 PLWHA 1,224 1,000 392 500 40 158 124 70 12 52 1 0 FY2012 FY2013 FY2014 Other entry points Pregnant women Breastfeedng women Male partners EID

After clinical staging and CD4 counts were performed, eligible PLWHA were identified and initiated on first-line treatment (AZT+3TC+NVP or TDF+3TC6+EFV§§§§) in health centers using Option A or Option B+, respectively. The nevirapine (NVP) was replaced by efavirenz (EFV) for patients receiving TB treatment. Pregnant women identified at Option B+ sites received HAART as recommended, and exposed children who tested positive for HIV by DNA PCR were also initiated on HAART. As a result of the PMTCT Pivot strategy, ProVIC’s increased efforts to provide treatment led to an increase in the number of PLWHA on HAART over time. Figure 36 shows the number of PLWHA enrolled in HAART by province and year. Katanga had an especially high enrollment in FY2014: 3,114 PLWHA on HAART, which can be attributed to (1) 51 of the 112 health facilities supported by ProVIC were in Katanga (46%); and (2) ProVIC piloted Option B+ (enrolling all HIV-positive pregnant women on HAART) at 11 health facilities in Katanga.

Figure 36. PLWHA initiated on HAART by year, October 2011–September 2014. 3500 3,114 3000

2500 Number of 2000 PLWHA on 1500 1,188 HAART 1000 812 432 500 279 126 183 194 158 17 19 56 5 34 0 FY2012 FY2013 FY2014

Sud Kivu Bas Congo Katanga Kinshasa Orientale

§§§§ AZT+3TC+NVP: zidovudine + lamivudine + nevirapine. TDF+3TC+EFV: tenofovir disoproxil fumarate + lamivudine + efavirenz.

49

Figure 37 shows the number of HIV-positive male partners of pregnant women placed on ART by province in FY2014. The greater number of HIV-positive male partners identified and placed on ART in Katanga, Kinshasa, and Province Orientale was due to the focus on increasing male involvement in PMTCT using the Mentor Mother and QA/QI approaches. ProVIC aimed to enroll 40% of HIV-positive male partners on HAART, and the project largely achieved this target in Kinshasa (39% enrollment) and Orientale (45% enrollment). The high level of enrollment in Katanga (71%) was due to the piloting of Option B+, where all male partners with a CD4 count of ≤500 were initiated on HAART. The low level of treatment initiation in Bas-Congo was due to the closeout of project activities in the province in FY2014.

Figure 37. Initiation of male partners on ART by province, October 2013–September 2014.

80 74 70 Number 60 53 (72%) of male 50 partners 38 40 33 30

20 15 (39%) 15 (45%) 11 10 3 (27%) 0 Bas Congo Katanga Kinshasa Oriental

HIV Positive Treatment

Summary of interventions Maximizing access to ART ProVIC-supported health facilities worked to improve the early identification of HIV-positive patients who were eligible for treatment. Through ANC as well as other, non-PMTCT entry points, eligible key populations and at-risk youth, STI cases, TB patients, at risk inpatients, and malnourished children were identified, enrolled, and maintained on ART according to the national protocol. Pediatric ART was initiated in 28 hubs sites (reference hospitals). ProVIC supported linkages between community- and clinic-based facilities to enhance timely testing and reduce the time lag between diagnosis and access to care, support, and treatment.

Improving the quality of ART and care services ProVIC provided a high-quality, comprehensive package of services to ensure that standards of care were consistent with the DRC government’s national guidelines on ART. These included integration of prevention (including Prevention with Positives) into care and treatment programs, promotion of adherence, and provision of comprehensive clinical care, including HIV treatment, management of opportunistic infections, TB screening and treatment, access to appropriate laboratory services, and comprehensive HIV support services. To ensure adherence to treatment and retention of clients, psychosocial support was offered to members of self-help groups and during home visits by providers and

50 by care and social workers. This contact and support helped sensitize PLWHA on the benefits of regular ARV use and the detection of serious side effects.

Facility staff received intensive training to build their capacity in high-quality service provision according to national guidelines and using DRC-trained and -recognized facilitators. ProVIC reinforced the capacity of its staff and site supervisors, who subsequently mentored site providers. Moreover, ProVIC set up quality improvement teams, expanding the approach to community members. The teams analyzed the prevention, care, and treatment process in-house and applied the recommendations of external tutors.

Supervision of quality improvement teams by certified trainers was intensified immediately following ART initiation. Supervisory visits were conducted every two weeks for the first month, then decreased to once per month after providers mastered all processes (eligibility criteria, adherence follow-up in accordance with DRC standards at each patient-provider interaction, tracking of loss to follow-up, and reporting).

Intermediate Result 3: Strengthening of health systems supported

ProVIC carried out a variety of interventions to strengthen the capacity of communities, local NGOs, health facilities, and government structures at the national, provincial, and health zone levels to contribute to creating a sustainable response to the AIDS epidemic.

Sub-IR 3.1: Capacity of provincial government health systems supported ProVIC worked with the DRC’s provincial government to strengthen health systems throughout the project’s duration. The project provided the 28 ProVIC-supported health zones with information technology equipment, office supplies, and limited financial assistance to support management and coordination functions as well as training on a variety of health and management topics, including commodity management. ProVIC also trained health care providers, community volunteers, and NGO workers on improved referral and counter-referral methods, which contributed to strengthening health systems and the quality of care provided to project beneficiaries. The project reinforced the government’s oversight role by involving government representatives in regular supervisory and monitoring visits of project-supported activities and by requiring ProVIC-supported health zones to submit monthly reports to the government for review and feedback. ProVIC was a key contributor in developing, adapting, and implementing national-level initiatives and strategies, with regular participation in numerous national planning and coordination meetings and workshops with other DRC stakeholders.

Evolution of health systems strengthening activities In the beginning of the project, ProVIC concentrated on strengthening the capacity of national entities, including the Ministry of Public Health, MINAS, and the Ministry of Gender, Family Affairs and Children. In 2012, in response to USAID’s recommendation to strengthen the peripheral (health zone) level of the DRC health system, ProVIC increased its engagement with health zones to implement project activities. The project provided financial and technical support to 28 of 518 health zones through Accords de Collaboration (collaborative accords). ProVIC’s support through these collaborative accords to health zones has strengthened the coordination, supervision, and communication capabilities of health zone management teams. Through these accords, ProVIC provided direct financial assistance to support coordination efforts, including funding to cover costs for office supplies, communications expenses, and

51 incidentals for data validation and activity coordination meetings. Financial and technical assistance was also provided to health zone management teams to allow them to better supervise referral and counter- referral systems and monitor commodities. Additionally, these collaborative accords covered transportation costs for health zone staff to monitor community-level activities. In addition, ProVIC engaged the intermediate (provincial) level of the health care pyramid by supporting specialized programs under the MOH, such as the PNLS, Programme National de Santé de la Reproduction (PNSR, National Reproductive Health Program), and Programme National de Santé de l’Adolescent (PNSA, National Adolescent Health Program).

Results ProVIC’s training methodology disseminated knowledge and built skills to strengthen the technical, management, and coordination capacities of stakeholders. ProVIC used MOH-approved training modules to certify individuals from the PNLS, social workers, caregivers, health facility staff, and other individuals as trainers, who in turn trained service providers. In total, 4,449 service providers were trained in topics relevant to project interventions, such as comprehensive PMTCT, HTC, and care and support services for PLWHA and OVC, as shown in Table 8.*****

Table 8. Service providers trained on various topics, by provider category and fiscal year, October 2009–September 2014. Service provider Training FY2010 FY2011 FY2012 FY2013 FY2014 Doctors and nurses Integrated HIV package 458 197 150 659 Laboratory Laboratory techniques; biomedical 53 150 technicians waste management Nutritional care; palliative care for Caregivers PLWHA; care for HIV/TB co- 61 infection Integrated package of services for Social workers 85 67 55 PLWHA and OVC Commodities/drug distribution and Pharmacists 47 management Health facility Datacard reporting tool 137 141 workers HIV prevention; gender-based 1,600 551 36 Community violence; family planning workers Mentor Mother approach 38 16

Summary of interventions In 2010, ProVIC conducted a baseline capacity assessment to identify gaps in the delivery of services provided by the provincial Ministry of Public Health; MINAS; and Ministry of Gender, Family Affairs and Children in Bas-Congo, Katanga, Kinshasa, and Sud Kivu. This assessment was also carried out in Orientale in 2012, following the project’s expansion into the province. Identified service delivery gaps at the provincial level included: • Poor coordination and planning.

***** The majority of ProVIC’s trainings for service providers were carried out in the first four years of the project, and training in the final year was focused on refresher, monitoring, and supervision in order to ensure the continuation of high-quality services.

52 • Weak M&E systems, with different data collection tools used by implementing partners. • Insufficient human resources and financial management capabilities. • Lack of integration of HIV/AIDS services in communities and health structures within health zones, largely due to the instability of local staffing. • Stockouts of commodities. • Fragile links between communities and health systems.

Following these assessments, ProVIC developed a capacity-building plan, in coordination with the PNLS and PNMLS, to address these gaps. Some specific provincial weaknesses that were targeted for capacity- building included building competency of a pool of provincial-level trainers of trainers, improving the referral and counter-referral tools and use of tools, and increasing provincial-level participation in quality assurance, largely through joint supervision. Provincial governments requested capacity-building at both the health facility and health zone levels for improvements throughout the health system. The plan was approved by provincial governments, and roles and responsibilities were assigned to various stakeholders.

Improving coordination within MINAS at the national and provincial levels One of ProVIC’s objectives was to support MINAS in strengthening and coordinating the management of OVC activities at the national level and to embed best practices for working with OVC at the national and provincial government levels. ProVIC provided assistance to MINAS in developing an M&E plan for its National OVC Task Force. The project convened a workshop to bring together all stakeholders working with OVC in the DRC to harmonize data collection tools and establish indicators for the National Strategic Plan for OVC. The workshop resulted in the production of a National Framework for Monitoring and Evaluation, aligned with the government’s National OVC Action Plan for 2010–2014.

ProVIC also helped MINAS to align its OVC training materials with the government’s national strategies. Materials were pulled from existing curricula and adapted through a series of stakeholder workshops, with representatives from MINAS, PNMLS, the PNLS, and local NGOs. As a result of this process, standardized modules and a training guide on OVC care were developed and disseminated, and ProVIC carried out trainings of trainers on the adapted curriculum in 2012 on behalf of MINAS. These trainings were conducted for 67 government social workers in Bas-Congo, Katanga, Kinshasa, and Sud Kivu Provinces to cascade best practices from the national to the provincial level. The trained individuals were then able to train social workers in their provinces to better support OVC.

Supporting PNMLS and PNLS coordination meetings at the provincial level Provincial capacity-building assessments identified coordination as a weakness across all ProVIC provinces. ProVIC consequently strengthened coordination within and among government agencies and with implementing partners by organizing quarterly coordination meetings at the provincial level. These meetings included representatives from PNMLS, the PNLS, and government partners (health facilities and NGOs) implementing HIV, gender, and OVC interventions. Attendees discussed the progress of activities in each province as well as challenges and potential solutions. The meetings also provided an opportunity to share strategies, implementation plans, and data to ensure greater harmonization of HIV, gender, and OVC interventions among implementers.

Building capacity for training service providers and caregivers ProVIC built training capacity at the provincial level by conducting trainings of trainers in each province. The trained trainers included doctors, nurses, laboratory technicians, pharmacists, peer educators, and community workers. ProVIC also supported trainings for service providers on relevant technical topics.

53 Attendees included doctors, nurses, pharmacists, social workers, and laboratory technicians working in supported health facilities across ProVIC’s five provinces. Training focused on disseminating information on technical standards to improve the quality and delivery of comprehensive services to project beneficiaries. Refreshers were provided periodically to ensure that new service providers received training. Refreshers were also adapted to address particular technical weaknesses of health facilities, as identified during project implementation, which allowed for continuous improvement in the quality of PMTCT, HTC, care, and support services.

Supporting joint supervision with government counterparts As part of the provincial capacity-building plan, ProVIC conducted joint monitoring and supervisory visits with staff from the PNLS, PNMLS, and MINAS to better support providers in delivering high- quality, comprehensive HIV services. This supportive supervision provided an opportunity for ProVIC senior staff to assess and coach service providers on enhancing the quality of services to meet DRC and PEPFAR standards. Joint visits by ProVIC and provincial government staff also helped to reinforce the link between community- and facility-based services and ensured two-way learning between ProVIC and the DRC government on the project’s progress and challenges.

Establishing a referral and counter-referral network for services in ProVIC sites Recognizing the importance of coordination to

ensure beneficiary progression through the HIV care continuum, ProVIC sought to strengthen and support referral systems. As highlighted in the Results sections of sub-IR 1.3 and Intermediate Result 2, establishing functional referral and counter-referral Masi PATH/F. Photo: systems improved client linkages to services. Pharmacist handing ARVs to a client.

The provincial capacity-building assessment also identified a need for up-to-date referral and counter- referral HIV service directories. In 2012, in collaboration with the provincial governments of Bas-Congo, Katanga, Kinshasa, Orientale, and Sud Kivu, ProVIC coordinated the creation of service directories in each province for referrals at three levels: government (both health and social services), NGOs, and community-based organizations (CBOs). These directories covered all HIV and related services offered in CCs and provided information on providers, their locations, and services offered. The directories were distributed to each institution and service provider (including CCs, self-help groups, and C2C groups) that were part of the service provision network.

In 2012, ProVIC assessed health-seeking behaviors in four provinces (Sud Kivu, Kinshasa, Katanga, and Bas-Congo) to better understand the motivations and barriers of clients for accessing services. The assessments revealed that the main barrier impeding access to services was the difficulty in finding effective and affordable health care. Other barriers included long waiting times and low quality of services. The assessments also showed that people tended to first visit traditional practitioners before turning to formal health facilities. The findings underlined the importance of CCs and community volunteers in mobilizing communities and referring and bringing clients to health facilities. Survey results were disseminated within the four provinces and formed the basis of ongoing efforts to continue strengthening referral networks.

54 In 2012, ProVIC organized a learning exchange visit to Initiative Privée de lute contre le VIH (IPC), an International HIV/AIDS Alliance partner in Burkina Faso. IPC exemplifies best practices in engaging governments to improve community and health structures, as well as referral and counter-referral systems. Learnings were used to develop referral and counter-referral tools and utilization guides and informed development of a strong referral and counter-referral network and procedures for HIV services.

Building the capacity of health zones One of ProVIC’s objectives was to build strong health systems at the health zone level. The project accomplished this by signing Accords de Collaboration with health zone offices. Under these agreements, ProVIC supplied health zones with equipment, office and medical supplies, and funding to support planning, coordination, and

communications functions, and health zones accepted accountabilty for monitoring, data validation, and referrals and counter-referrals.

Photo: ProVIC Photo: Developing PMTCT communication tools Demonstration toolkits developed in partnership with C-Change and the PNLS. ProVIC collaborated with the Communication for Change (C-Change) project, the PNLS and PNMLS, and other partners to develop communication tools to facilitate outreach by peer educators, relais communautaires, and other community actors and volunteers. These tools included boites d’images (demonstration storyboards), flashcards, and visual aids covering a wide range of prevention messages and educational information on HIV. Information covered methods of HIV transmission and strategies to prevent transmission; effective condom use; how to seek HTC services; partner involvement in prevention and testing; treatment and ARV administration; and PMTCT. The comprehensive visual toolkits equipped community volunteers and peer educators to more effectively reach community members and engage them in decision-making on HIV prevention efforts.

Integrating family planning with HTC services As part of ProVIC’s efforts to integrate family planning services with HTC, the project worked with the PNLS to train service providers in family planning and equipped health centers with necessary supplies, including contraceptives. After recognizing a capacity deficit within the MOH family planning working group, ProVIC revived the working group by calling for the need to integrate family planning into HTC activities. By 2014, ProVIC offered family planning counseling in all 112 supported health facilities, and 67 health facilities offered evidence-based contraceptive methods.

Updating the PITC trainer’s guide and data collection tools In 2014, ProVIC worked with the PNLS to update the PITC trainer’s guide and data collection tools, which include a training manual, job aides, norms and standards for PITC, and a pocket guide for health care providers. These tools provide recommendations and key communication points on HIV prevention and testing, an outline of the testing and counseling processes, and guidance on obtaining consent and maintaining confidentiality. ProVIC also produced a comprehensive PITC trainer’s guide, which provides facilitators with training content, participant activities, and guidance for different populations.

55 Strengthening the technical capability of government entities to provide GBV services ProVIC worked with government partners—including the Ministry of Gender, Family and Children at the national level and the PNSR, PNLS, and PNSA at the provincial level—to increase their knowledge and technical capacity to offer high-quality GBV services. In 2012, through the partnership with the PNSR, ProVIC enrolled 12 individuals, including three health zone medical chiefs, in training provided by the Centre d’Information Stratégique sur le VIH/SIDA (Center for Strategic Information on HIV/AIDS) to become national trainers of community stakeholders and providers for the prevention and management of GBV cases. In 2014, ProVIC supported the Ministry of Gender, Family and Children in a workshop to strengthen synergy between the ministry, magistrates, and lawyers in Kinshasa. The workshop led to the signing of a commitment to collaborate on advocacy and other efforts to increase legal support for GBV survivors. ProVIC also helped the ministry disseminate information about sexual violence legislation.

Sub-IR 3.2: Capacity of nongovernmental organization providers improved ProVIC’s strategy to strengthen community response to HIV was carried out in partnership with 14 local NGO implementing partners, which established CCs, self-help groups, C2C groups, and networks of community volunteers to increase services provided to beneficiaries. To enhance the work of these partners and to ensure the sustainability of interventions, ProVIC strengthened the groups’ capabilities to implement high-quality programs effectively and efficiently. Enhancing adherence to USAID rules and regulations was a key objective. Efforts focused on improvements in financial management, administrative systems, and M&E.

Evolution of NGO capacity-building activities Through a competitive process, ProVIC selected 14 NGOs to serve as the project’s main community-level implementing partners. In the first two years, ProVIC worked to improve the organizational and technical capacity of these partners. In 2013, in response to the Strategic Pivot, ProVIC began to substantially reduce the level of support for these partners as the project shifted emphasis to health facilities.

Results With capacity-building support from ProVIC, local implementing partners successfully carried out their scopes of work and established CCs that provided essential services to beneficiaries in their communities. Following the conclusion of community mobilization activities and ProVIC’s support to NGO partners, the project worked with NGO partners to transition CCs to existing community structures to ensure the sustainability of improvements. Table 9 shows how the 49 CCs established by ProVIC were transitioned following the end of project funding.

Table 9. Transition of CCs following the end of ProVIC support, by province. Province Number of CCs Transition Sud Kivu 10 Recognized by their respective health zones as CBOs Bas-Congo 11 Oriented to PNMLS and registered as CBOs Relais communautaires and other social workers trained by ProVIC CCs were Kinshasa 10 integrated into health zone activities Katanga 13 Integrated into existing CODESAs in their respective health areas Orientale 5 Integrated into existing CODESAs in their respective health areas

56 Summary of interventions In early 2010, ProVIC held a competitive solicitation to identify NGO implementing partners to lead the CC approach and carry out all community-based activities. Local NGOs subsequently submitted 456 concept notes. After a thorough review process, 14 groups were selected as standard grantees.

Building the organizational and technical capacity of NGO partners To better understand the organizational systems and needs of grantees, ProVIC developed and produced an integrated capacity-building strategy and work plan. Project staff adapted the organizational capacity assessment tool from USAID’s flagship New Partner Initiative and piloted the tool with NGO partners in Kinshasa. The ProVIC team subsequently used the adapted tool to assess the managerial and technical capacities of all the grantees in 2011. The findings formed a baseline for each grantee, and a Technical Assistance Priority Plan was developed to serve as a roadmap for capacity-building activities.

Partners received training based on identified gaps in knowledge and skills. Because the assessment showed that financial management and administration was a major gap area, ProVIC conducted three financial management and USAID compliance training sessions for finance officers and NGO directors. Training topics included USAID cost principles and regulations; procurement; allowable, allocable, and Considerations for key populations reasonable expenditures; audit preparedness; internal The MSM community in the DRC has an controls; marking and branding; reporting; recordkeeping; HIV prevalence rate more than 10 times and cost-share. The baseline capacity assessments also greater than that of the general revealed the lack of an electronic accounting system among population, yet stigma and discrimination often hinder this group from accessing grantees, so ProVIC purchased and provided training on services. ProVIC worked closely with the Quickbooks accounting software to enable more accurate PNLS to adapt the peer educator training and faster financial reporting. Following these trainings, module for key populations and ProVIC observed a marked improvement in the quality of incorporated information specific to financial reporting and documentation and better adherence counseling MSM on HTC, treatment, care, to financial reporting timelines. and support. This addition to the training module provided peer educators with tools An organizational development specialist consulted with to tailor HTC inventions to effectively reach ProVIC technical staff, regional coordinators, and grant MSM and to help this group access services. managers to develop a joint strategy on organizational development to complement the financial strengthening trainings and ensure that ProVIC had the capacity to support its partners to effectively deliver planned interventions. In addition, ProVIC provided training in technical areas, including HTC and care and support, and in approaches used by project teams, such as the CC and C2C approaches.

With PEPFAR’s Strategic Pivot in 2013, ProVIC’s NGO capacity-building component was greatly reduced in order to focus efforts on health facilities. However, ProVIC continued to provide assistance to NGO partners to update their financial and administrative manuals and offered mentoring and coaching on grants and financial management. Most of this technical assistance was provided through site visits to ensure that NGO partners put recommended practices into place and to better tailor technical assistance to the specific issues of each NGO.

Supporting quarterly grantee review meetings To ensure that lessons learned and best practices were shared among grantees, ProVIC supported quarterly review meetings in which grantees discussed their performance and planned activities for the

57 subsequent quarter. These meetings helped grantees learn from each other and share potential solutions to problems, contributing to the continued improvement of services.

Helping communities design sustainability plans The transition of CC activities was managed through phased exit planning. The development of sustainability plans was a central part of ProVIC’s exit strategy. First, ProVIC helped CCSCs develop sustainability plans that clarified current roles, responsibilities, and relationships and that identified the long-term linkages between internal and external stakeholders that communities need to ensure the continuity and sustainability of community-based activities conducted under ProVIC. As another key part of some of the sustainability plans, the project organized meetings with the health zone management staff (Equipe Cadre de Zone de Santé) to reinforce visibility of CCs and gain official recognition and integration of CCs into the local health system and recognition of the structures as CBOs. In many cases, the sustainability plans included the submission of a formal application to local authorities for CCs to be registered as CBOs. Several CCs became CBOs, and relais communautaires and social workers from others were incorporated into existing health zone structures and CODESAs.

ProVIC supported the CCs to transition from ProVIC support to independent sustainability. Following the end of technical and financial support from ProVIC, CCs were integrated into the local health system, in coordination with ProVIC and PNLS. Some implementing partners received funding from UNICEF to work on child protection activities at the local level. The CC/CODESAs continue to work step-by-step under the supervision of health zone, to ensure the link to specific health facilities and between community-based and clinical care, and encourage women of reproductive age and their partners to visit the ANC.

Sub-IR 3.3: Strategic information systems at the community and facility levels strengthened ProVIC’s efforts to strengthen strategic information systems focused on two objectives: (1) building a strong project M&E system; and (2) improving community, facility, and national strategic information systems for monitoring and reporting on the DRC’s and USAID’s responses to the HIV epidemic. While developing a strong M&E system to report on PEPFAR indicators, ProVIC ensured that DRC national guidelines and indicators were included. The project built the capacity of staff in health facilities, NGOs, and communities for data collection and reporting, and project partners learned to monitor and report data for both project and DRC information systems.

Evolution of information systems activities The PMEP, work plan, and Country Operational Plan were updated each year. In addition, project staff periodically revised information systems based on the needs of specific project phases, such as by adding new indicators to collect data related to gender-based violence for Phase 2. The Strategic Pivot in 2013 brought a substantial increase in the volume of data collected—due to the addition of new local health facility partners, the engagement of health zone partners, and the addition of new PEPFAR and project indicators. ProVIC revised the PMEP to include appropriate indicators for monitoring the continuum of care while removing others, and to set realistic targets for the remaining project years. The new indicators required architectural changes to ProVIC’s M&E system. Both existing and new health facility partners were trained and mentored on the revised system, particularly in relation to recording data on service provision. In the final project year, ProVIC made additional changes to the reporting system to provide accurate data that reflect PEPFAR’s most recent indicators (the MER: Monitoring and Evaluation Reporting).

58 Results Analyzing data in real time Strengthened systems and capacity for data collection and reporting ProVIC, with the help of Vera Solutions, developed ProVIC continually engaged a wide range of the idea of creating a cloud-based M&E database using the Salesforce platform. Health facilities implementing partners in M&E training and uploaded data for ProVIC indicators into capacity-building efforts; more than 228 participants Microsoft® Excel® datacards, which were were trained in the use of datacards. Although many submitted to ProVIC on a monthly basis. The project partner staff had never used a computer at the information in these datacards was uploaded into beginning of the project, all partners collected and the ProVIC database on Salesforce, and the cloud- reported data electronically by the end of the project. based feature enabled program staff in various Implementing partners, ProVIC staff, and other provinces to easily access, analyze, and share data. The database also enabled program managers to PEPFAR partners all have a common understanding measure progress toward milestones in real time of indicators and can use the information to report for and make adjustments to improve performance both project and national purposes. and achieve established targets.

Improved quality of data collected ProVIC used routine data quality audits (RDQAs) to coach implementing partners to make improvements based on findings. Findings ranged from mistakes in data entry (date of birth different for same beneficiary) to failure to use some data collection forms. At each RDQA, ProVIC staff made recommendations to improve data quality, and ProVIC and partner staff together would develop an action plan to address issues. Data quality improved Masi PATH/F. Photo: as issues were identified, and partners were coached Nurses upload data from registers onto the to make corrections or to understand more fully the Salesforce platform. data requirements for the next round of reporting.

ProVIC also used a peer-to-peer local capacity development model to strengthen partners’ M&E capabilities and improve data quality (this model is further explained in Section D). ProVIC piloted this model in Kinshasa in FY2013, with PSSP acting as the “lead grantee” (mentor), monitoring and providing technical assistance on M&E to two “learning grantees” (mentees). Results of this approach included the quick adoption of desired M&E practices. For example, PSSP provided basic technical assistance to the learning grantees on a filing system for M&E data (records labeled and stored in binders, and organized chronologically), which the learning grantees implemented under PSSP’s supervision. The improved filing and organization of partners’ data records yielded more accurate and thorough project reporting.

Summary of interventions Coordination and strengthening efforts at the national and provincial levels Both PNMLS and the PNLS participated in the design of the ProVIC PMEP to ensure that national indicators were integrated into the project’s reporting system. MINAS was invited to the annual work plan workshop, where discussions explored areas of collaboration and support. ProVIC’s data collection and reporting tools were developed based on existing tools collected from partner organizations and agencies (e.g., PNLS, PMLS, MEASURE Evaluation). ProVIC worked to harmonize project M&E objectives with those of partner organizations.

59 Throughout the project, ProVIC staff coordinated closely with national and provincial officials to support efforts related to strategic information and M&E, either by participating in meetings or working side by side. For example, ProVIC financed and staff participated in the review of the DRC 2010 National AIDS Spending Assessment, and ProVIC staff worked side by side with provincial counterparts to support development of the Provincial Health and Development Plans, 2011–2015.

Strengthening information systems at the community level Through provision of data collection tools, training, and one-on-one coaching, ProVIC built the capacity of NGO and community-level partners to monitor and track project information on a monthly basis in line with national reporting requirements.

ProVIC staff also trained representatives from local partner organizations to use participatory learning and action techniques to conduct qualitative, participatory baseline assessments in 2011 in two CCs in each of ProVIC’s operating provinces (Bas-Congo, Katanga, Kinshasa, and Sud Kivu). These assessments, using focus group discussions, identified issues and improved understanding of community perceptions concerning HIV/AIDS. Investigators used visual tools such as community mapping, polarization diagrams, and problem-solving trees to assess use of and access to existing HIV/AIDS services and knowledge and behavior related to HIV/AIDS. The assessments equipped NGOs and health facilities with the knowledge needed to develop and implement high-impact interventions to address risky behaviors and knowledge gaps and better target interventions within communities and health zones.

ProVIC conducted routine data quality analysis to identify issues with data collection and reporting and provide feedback to partners. Repeat visits to conduct RDQA, provide additional coaching on any issues found, and follow up on action plans from prior visits helped to show improvements in data accuracy and reliability over time. Some care and support indicators, however, were challenging because partners struggled to report on the number of individuals served rather than the number of services offered.

Strengthening information systems at the facility level Through a system of training and one-on-one coaching with partners, ProVIC supported public and private hospitals and clinics to provide high-quality monthly data on service provision. Additional training was provided as needed when the system changed, reporting requirements changed, or new partners were added. For example, with the phased changes to the database and data collection systems, ProVIC formally trained 137 partners in 2012 and 153 in 2013.

To ensure data quality and completeness, ProVIC provided technical support and guidance to implementing partners through regular supportive monitoring visits and RDQAs and conducted joint monitoring site visits to encourage greater interdepartmental collaboration and dialogue on M&E and technical issues. Starting in 2011, ProVIC conducted an average of one joint visit per quarter per province with the PNLS and PNMLS, as well as with health zone staff. These visits covered issues such as understanding of the minimum package of activities to be counted under an indicator (complex PEPFAR Indicator P7.1D) and low reported activity (PEPFAR Indicators C5.6D and C2.4D).

PEPFAR has made changes to the reporting system to retrieve accurate information about the quality of its support to countries. The Next Generation Indicators will be replaced by the MER indicators. With some exceptions, the MER indicators will be reported for FY2015. PEPFAR organized a three-day workshop to brief its implementing partners on guidelines for the new reporting system. The ProVIC Chief of Party, national managers for M&E activities, and other members of the technical team (including

60 PMTCT, Community Mobilization, and Care and Support) attended this briefing. The ProVIC National M&E Specialist, in turn, organized an orientation for all ProVIC technical staff on the MER.

ProVIC M&E staff also participated in the committee meetings of Global AIDS Response Progress Reporting 2014 as regular members and attended the validation workshop for the production of the annual UNAIDS country report. ProVIC programmatic data related to MSM were greatly appreciated at this meeting because these are the only readily available data on this key population group in the DRC. As a result, the ProVIC MSM data were included as part of the country report.

61

Community- and facility-based gender-based violence prevention and response services strengthened

Sexual and gender-based violence, including harmful gender norms, power inequity in relationships, and exposure to physical, emotional, and sexual violence, are all key issues related to HIV risk. To address these challenges, ProVIC integrated GBV prevention and response efforts at the community and health facility levels.

The implementation of activities for the integration of gender and GBV within ProVIC began in 2012, with Phase 2. This integration initially involved Kinshasa and Province Orientale and was later extended to Katanga and Bas-Congo. Initial GBV integration included the implementation of prevention activities ProVIC Photo: Sensitization activity carried out in through CCs, especially community volunteers and peer educators, to help Kikimi, Kinshasa. change harmful socio-cultural norms that perpetuate gender inequalities and promote GBV. Trained community volunteers and peer educators educated communities about GBV-related laws and provided information about GBV services available at health facilities. With the Strategic Pivot in Phase 3, GBV integration focused on screening and medical and psychosocial care for survivors of GBV at 67 supported health facilities. Health staff at ProVIC-supported facilities proactively identified PMTCT and other facility clients who had experienced GBV and responded with care and support as needed.

Results During a two-year period, the most common form of identified GBV involved pregnant women (see the figure on the left). Project efforts resulted in 51,141 people receiving GBV information, including 19,853 males (33.8%) and 31,288 females (61.2%). Most were 25 years of age or older (79.8%). After the decrease in community-level activities and increase in trainings for health care workers, the number of people receiving GBV messages decreased from 31,593 in 2013 to 19,548 in 2014 (see the figure on the right). In contrast, the number of people who were screened more than tripled, from 16,908 in 2013 to 61,770 in 2014. This was related to the integration of GBV screening into PMTCT services, as well as the extension of activities in all provinces supported by ProVIC. Screening included both females (91.7%) and males (8.3%). Capacity strengthening efforts, combined with closer monitoring of health care providers, led to 89.2% of identified GBV survivors receiving appropriate management of their cases during 2014, compared with 64.3% in 2013 after the start of the program. About 20% of female GBV survivors identified through GBV screening during PMTCT visits were 24 years old or younger.

Types of identified GBV cases by beneficiary category, October 2012–September 2014. GBV services provided in health facilities and communities.

62

Number of GBV services offered from September 2013 to October 2014.*

1600 1,452 1400 1200 1000 800 Numberof GBV services offered 543 600 400 200 112 68 41 24 0 HIV testing GBV counseling PEP kit Referrals Wound care STI treatment GBV service type PEP: post-exposure prophylaxis. * Individuals may have received multiple services.

GBV activities carried out in ProVIC-supported health zones are summarized below.

Community level • Training of community volunteers, peer educators, social workers, and caregivers on GBV issues and monitoring. Training covered harmful gender norms, gender equality, legislation on sexual violence and child protection, male involvement in PMTCT, and support for GBV survivors to access services in accordance with national standards and guidelines. Awareness messages were addressed to the general population but with a focus on youth. • Psychosocial support by social workers for GBV survivors in self-help groups. • Strengthening of referral systems for comprehensive GBV care.

Health facility level • Adaptation of the GBV screening tool, training of providers to use the tool, and effective supportive supervision, including facility-based screening. • Screening by facility staff to identify GBV survivors, and provision of GBV-related services. • Detection of GBV among men, and screening for GBV in some of the PLWHA self-help groups and OVC C2C support groups. • Clinical management of survivors of GBV, including counseling and immediate psychosocial support, administration of post-exposure prophylaxis kits for survivors of sexual violence arriving at the clinic within 72 hours after the assault, STI treatment, and wound care. • Development and dissemination of project policies related to child protection and sexual abuse.

63

C. Lessons learned

ProVIC has demonstrated that it is possible to provide high-quality prevention, treatment, and care in the DRC in spite of all the complexities associated with the DRC’s status as a post-conflict country. The DRC’s lack of infrastructure and fragile health systems require multiple adaptions to ensure performance while the government rebuilds its systems following years of war and decline. Keys to ProVIC’s success has been close coordination and planning with the government at the national, provincial, and health zone level and capacity building of government entities.

At the national level, ProVIC aligned project activities with the 2010–2014 National HIV/AIDS Strategy and also contributed to the 2014–2017 strategy, thus ensuring ProVIC’s interventions provided technical leadership to the DRC’s HIV/AIDS program. Furthermore, when introducing new interventions, such as Option A, Option B+, the Mentor Mother program, and the QA/QI program, ProVIC worked intensively with PNMLS to ensure technical alignment and ownership of new interventions, which was critical to dissemination and implementation. At the provincial level, ProVIC reinforced provincial coordination by integrating into Provincial Action Plans, semi-annual and annual reviews of the provincial HIV/AIDS program; carrying out joint supervision of ProVIC activities; and supporting efforts to build the capacity of provincial staff. At the health zone level, ProVIC also reinforced the coordination and supervisory functions of health zones, and supported the process for action plans at the health zone level. ProVIC’s close collaboration across various levels of the DRC’s health system was central to the project’s successes and ability to deliver high-quality prevention, care, and treatment programs.

The narrative below provides additional lessons learned during the implementation of ProVIC, by Sub-IR, to help inform future programs on how to successfully implement HIV/AIDS activities in the DRC.

Sub-IR 1.1: Communities’ ability to develop and implement prevention strategies strengthened Building sustainability takes time and requires strong cohesion among community actors. When ProVIC Community ownership introduced communities to the CC approach, the Not all communities become champion communities. Time and effort, but it is through the strength to persist communities were asked to identify challenges they that this [status] is achieved. To do this, you must faced and community resources that could be identify the challenges you face, set goals, and set leveraged to address them. This process required forth on the tasks at hand. strong leadership and cohesion among community – Biyela Champion Community Steering Committee member representatives serving on the CCSCs, strong monitoring and support from partner NGOs, and creative solutions. Ensuring the sustainability of the process also took time, and ProVIC found that multiple annual “CC cycles” were needed to ensure true community ownership of plans.

Urban and rural CCs are driven by different dynamics. Rural communities, which tend to have a clearer sense of common interests and more stable populations, where “everyone knows everyone,” are better suited to the CC approach than urban communities, which tend to have less cohesion. This is not to say that urban CCs cannot be successful. Urban communities can set objectives and meet them in the same way that rural CCs do, but volunteerism is less likely to hold over time due to multiple factors, such as the myriad opportunities that urban life offers and greater mobility of individuals within urban areas. In rural areas, community activists who form the majority of CCSCs—such as priests, members of church

64

congregations, teachers, and government workers—tend to be more settled in their communities. The consequence is greater turnover of CCSCs and less continuity of action over time.

Another lesson learned was that flexibility is key. In urban areas, ProVIC adapted some aspects of the model to better meet the needs of urban populations. For example, rather than grouping a “community” solely based on geography, ProVIC created “communities” of key populations, which were built around networks of MSM and CSW living in a specific urban area. Through this flexible approach, the project enabled MSM and CSW networks to benefit from the structure, support, and information-sharing of the CC model. Additionally, given the limited quantity of high-capacity local partners in some contexts, ProVIC provided direct oversight of CCs, rather than working through local NGOs, to better meet the needs of populations in these areas.

Sub-IR 1.2: Community- and facility-based HIV testing and counseling services increased and enhanced Referrals between community- and facility- based services are challenging. One of the most difficult issues facing HIV prevention programs is managing and documenting referrals from one service or service provider to another, because the health care referral system is extremely weak. The MOH estimates that only 2% of referrals are documented correctly in the DRC. While this

problem is significant for referrals between health facilities, ProVIC’s biggest challenge has been improving referrals (and the documentation of these referrals) between community-level services, such as mobile HTC, and the health

Photo: PATH/F. Masi PATH/F. Photo: facilities that provide treatment.

Mobile testing organized on World AIDS Day, December 1, To improve referrals and documentation of 2012, Bandalungwa commune, Kinshasa. referrals, ProVIC developed, jointly with the PNLS, referral and counter-referral slips, which were distributed to all ProVIC-supported health facilities. Health care workers at the community and facility levels were coached to use these slips and provided with strategies and resources for following up with patients by phone, SMS, and home visits. ProVIC also worked closely with health zone management teams to emphasize the importance of revitalizing referral systems within health zones. The referral system only improved following months of targeted technical assistance and follow-up.†††††

Sub-IR 1.3: Prevention of mother-to-child transmission of HIV services improved PITC is effective for identifying HIV-positive people and initiating HAART. The use of PITC at various entry points—including labor and delivery, TB and STI services, antenatal and under-five clinics, and malnourishment treatment units—has proven to be an effective strategy for initiation into HIV care and treatment, including PMTCT. By encouraging health care providers to provide testing and counseling for

††††† Data showing improvements to referral systems are presented in sub-IR 1.2 and Intermediate Result 2 in the Results section.

65

HIV during service visits, the number of individuals tested for HIV can be increased, which subsequently increases the identification of HIV-positive individuals and their enrollment on HAART (refer to sub-IR 2.3 for results). The number of women identified as HIV positive through PITC, particularly at labor and delivery, increased continuously from 2012 through 2014. In 2012, 18 women tested HIV positive at labor and delivery; in 2013, 240 tested positive; and in 2014, 346 tested positive in ProVIC-supported PMTCT sites and other entry points.

Implementing QA/QI principles improves outcomes. Quality improvement and assurance of quality are essential components to strengthening and sustaining service delivery to populations living with HIV/AIDS. To pilot QA/QI activities as part of the project’s commitment to improve PMTCT services, ProVIC selected 14 maternity hospitals (six in Kinshasa, six in Katanga, and two in Orientale). The results, after three months of activities in all targeted facilities, were notable, and indicators of collaboration improved. For example, sites implementing the QA/QI approach demonstrated improved HIV testing of male partners compared to sites without QA/QI (please see Figure 29).

The Mentor Mother approach was associated with improvements in the retention of HIV-positive mothers in treatment. To address the challenge of retaining mother-baby pairs in the PMTCT platform, ProVIC designed and implemented the Mentor Mother approach. Mentor Mothers facilitated group talks on HIV education and PMTCT, referred mother-child pairs to PMTCT, and counseled them to adhere to the services, as well as provided psychosocial support and counseling services to HIV-positive women and their families. Mentor Mothers were associated with improvements in retention and adherence to treatment regimens and care and support services; more than 80% of HIV-positive women were retained in self-help groups, and HIV testing rates among male partners of pregnant women increased, as did follow- ups of mother-child pairs. Mentor Mother activities were also associated with helping identify patients lost to follow-up and re-engaging them in care. Depending on the results of the larger evaluation of Mentor Mothers following our pilot (see pg. 41), ProVIC will continue advocating to the DRC government for the integration of the Mentor Mother approach in the minimum package of services provided at health facilities and the extension of Mentor Mother activities to other sites.

Sub-IR 2.1: Care and support services strengthened Self-help groups help improve the quality of life of PLWHA. Our observations of self-help groups and feedback given by PLWHA suggest that these groups are highly beneficial for PLWHA, and should be retained and even expanded in future programming. Self-help groups fostered solidarity among PLWHA, and helped reduce self-discrimination and the clandestine existence of some PLWHA. The groups allowed for the provision of psychological support to a greater proportion of PLWHA and provided renewed hope to the most vulnerable individuals. Within the groups, PLWHA improved their knowledge of HIV and other health issues, including general hygiene, TB, STIs, nutrition, and treatment adherence.

Sub-IR 2.2: Care and support for orphans and vulnerable children strengthened Identification of OVC and their specific needs is essential for providing the most effective interventions to meet those needs. Using standardized tools to assess OVC needs is an essential first step in identifying the most vulnerable OVC and their specific needs, which vary from child to child. The criteria and tools to be used (e.g., PEPFAR’s Child Status Index, the OVC identification sheet, and OVC monitoring tools) should be established and developed at the start of the project.

66

Sub-IR 2.3: HIV treatment improved in target areas Task-shifting is a critical element to enhance the prescription and initiation of HAART at PMTCT and other entry points. The DRC’s national guidelines stipulate that only doctors may prescribe ARVs. Given this restriction and the presence of facilities that do not have their own physicians, ProVIC rotated visiting physicians to provide prescription capabilities at these facilities twice a week. However, this approach is disadvantageous because some patients are forced to wait or asked to return to facilities on another day to be seen by the visiting physician for initiation of HAART. Under ProVIC, trained nurses began prescribing ARVs, under the supervision of facility doctors, at Libondi Health Center in Kinshasa. A nurse debriefed the doctor about patients enrolled on HAART when the doctor was away. This practice helped to address coverage gaps by empowering nurses to initiate patients on

HAART the same day their eligibility is determined to avoid potential loss to follow-up and ensure patients’ continuation along the continuum of care. Although this practice has not formally been adopted by the PNLS,

ProVIC advocated for the redefinition of the content and Masi PATH/F. Photo: context of task-sharing at the PNLS to officially allow A medical worker listens to a pregnant woman’s nurses to prescribe and manage ARVs. belly with an ear trumpet.

The peer-to-peer local capacity development model is a cost-effective approach to improving the quality of service provision. This model organizes health facilities into service delivery networks to build capacity to provide high-quality PMTCT and HAART services. High-capacity health facilities (“lead” sites) are linked with lower-capacity partner sites (“learning” sites) to provide mentorship, technical assistance, and supportive supervision. Lead sites support capacity-building for learning sites related to service quality, data collection, and recordkeeping. ProVIC began using this approach in FY2012 and ultimately organized 112 project-supported health facilities into networks of 27 lead sites and 85 learning sites. This model provides a cost-effective, sustainable approach for developing local capacity and has been approved by the PNLS.

67

D. Challenges and proposed solutions

HTC services Challenge Proposed solution Key populations of MSM and CSW are a driver Although ProVIC strongly affirms the central role of the HIV epidemic in the DRC. Targeting these of the health zone in fighting the transmission of populations and providing testing, referral, and HIV, services to MSM and CSW should be an treatment services should be a priority for exception to the rule. Programs should be USAID programming. However, offering these permitted to offer counseling, testing, and referrals services to key populations through the health in critical hot spots and then actively follow up zone is difficult because these populations are with these individuals to ensure they access care highly mobile and best reached in hot spots, and treatment services where it is most convenient which may not be the health zone of residence for for them, not necessarily in the health zone where these individuals. Expecting individuals to be they were tested for HIV. tested and receive services in the same health zone is not realistic for most key populations.

PMTCT services Challenge Proposed solution The network for EID is fragile due to the ProVIC provided funding to cover transportation existence of a single national PCR laboratory in fees for EID samples to be sent from spoke Kinshasa. facilities to hub facilities within health zones. Every week, all hub sites transferred their samples to ProVIC’s provincial offices; from there, samples were transported to the national PCR laboratory in Kinshasa by DHL. Information was also sent to ProVIC’s EID coordinator (who is a member of the PMTCT/ART team and responsible for gathering all information related to EID). To support the network, the EID coordinator conducts follow-up visits to the PCR laboratory to check on the status of testing and collect test results. Test results are then relayed to health care providers through ProVIC’s provincial staff. ProVIC also engaged with provincial PNLS to improve the functioning of the sample transportation system and to ensure that results are turned around in a timely manner. The PNLS is implementing this approach in FY2015.

The opening of a regional PCR laboratory in 2015 in Lubumbashi will help further alleviate the burden placed on the national laboratory in Kinshasa and will allow for a quicker turnaround time for EID results in Katanga. A needs assessment carried out in ProVIC- ProVIC worked with these entities to build their supported sites revealed that a significant volume data collection capacity. The project also took on of PMTCT data was missing at the provincial the PNLS’s role of printing and distributing data level (PNLS). Some data were not segregated, collection tools because the PNLS no longer has

68

Challenge Proposed solution which made data analysis difficult for some funding to do this themselves. PEPFAR should facilities. Data collection tools, registers, and consider providing support to the PNLS at the forms are also prone to stockouts, which provincial level for the duplication and distribution negatively affects the collection of accurate data. of data collection tools to enable all health facilities within a province to have standardized tools. It is difficult to provide continuing care for HIV- ProVIC organized an integrated HIV training, positive children identified through EID. Most which included information on pediatric testing, pediatric facilities are located far from ProVIC- care, and treatment services, for all health care supported PMTCT facilities, so families of providers in order to strengthen their technical infants with HIV have to travel a great distance to knowledge and capacity to provide pediatric access a pediatric clinic. services. Additionally, ProVIC adapted existing job aides to incorporate information on pediatric services (including information on clinical and biological monitoring for children, medicine dosage, and forms of medication). These adapted job aides and data collection tools were provided to health facilities as another mechanism for increasing access to pediatric services.

To address more complicated cases, ProVIC arranged for doctors at hub facilities to travel to spoke facilities once a month to provide additional expertise and assistance. Using these approaches, ProVIC was able to improve care and treatment services provided to HIV-positive children. Low rates of women return to deliver at the ProVIC piloted the Mentor Mother approach as a PMTCT site where they were tested or received method to improve the retention and adherence of PMTCT services. women in PMTCT. ProVIC also provided maternity fees to HIV-positive pregnant women, strengthened the supervision of providers during home visits, and improved the referral system for women progressing from ANC to labor and delivery services. Male partners often do not participate in PMTCT ProVIC encouraged extending the hours that services. services were available, including offering services during weekends and on holidays to allow men to access services outside of the workday. ProVIC also improved communication materials provided to male partners by disseminating messages in local languages to explain the importance of male partner involvement and inviting men to accompany their wives on visits to antenatal clinics and health facilities for maternal and child services. ProVIC also used visual messaging on HIV/AIDS to promote male partner involvement and encouraged male involvement through the Mentor Mother and QA/QI approaches.

69

HIV treatment services Challenge Proposed solution Delayed enrollment of HIV-positive patients on ProVIC piloted a program that encourages trained HAART at health facilities that do not have their nurses to prescribe and enroll HIV-positive clients own physicians, which results in the need for on HAART when physicians are not available. HIV-positive patients to return to these health ProVIC was also involved in discussions with the facilities on another day when a visiting PNLS on task-shifting and is providing support to physician is present and increases opportunities the PNLS on developing a national policy on task- for loss to follow-up. shifting. Difficulties tracking patients enrolled in ProVIC- ProVIC’s online M&E database on Salesforce was supported care and support services and enrolled designed to better track beneficiaries receiving in ART. ProVIC encountered difficulties at the care and treatment services by capturing data beginning of the project with counting reported by ProVIC’s implementing partners on beneficiaries receiving care and support services. unique individuals and reporting services that each Prior to the introduction of ProVIC’s online individual received. M&E database, implementing partners would simply report the total number of beneficiaries The introduction of Tier.Net in Q4 of FY2014, who received a type of service for a particular software designed for PLWHA cohort period. ProVIC applied correction factors to data management, has helped to better track and received from implementing partners to avoid monitor PLWHA on ART to ensure adherence to counting errors, but this method was not optimal care and treatment programs and identify those lost for accurately tracking beneficiaries. to follow-up, as it also tracks missed appointments, etc. Difficulty providing analysis of CD4 counts on PIMA™ analyzers should be provided to high- the same day that an individual is diagnosed as volume spoke sites that are far from hub sites to HIV positive due to the long distances between allow for early determination of HAART some health facilities and sites that have a eligibility of HIV-positive individuals. PIMA™ analyzer. Limited number of technical staff to manage Interns can be used to provide additional support at activities in high-volume health facilities. the provincial level (one intern to cover seven PMTCT/ART sites) to enhance the quality of care and improve the retention of PLWHA in treatment programs. Inadequate equipment at ProVIC sites to conduct PEPFAR should finalize the procurement of biological monitoring for patients. While waiting equipment for hematology and biochemistry for the procurement of equipment by SCMS, through SCMS so that high-quality care and ProVIC hoped to identify interim solutions, such follow-up can be provided to patients. as using already available equipment in health zones, but this solution was deemed impractical and suboptimal due to stockouts and transportation issues that were out of ProVIC’s control

70 Annex A. Monitoring and evaluation table

Please see attached.

Annex B. Environmental monitoring and mitigation activities

As a health project working in clinics and dealing with biomedical waste, the primary environmental monitoring and mitigation activities ProVIC implemented concerned the appropriate disposal of biomedical waste generated through project activities. In Year 1, ProVIC developed and implemented a comprehensive plan and guidelines for hygienic and environmentally safe management of hazardous biomedical waste. This included site assessments, identification of environmental and safety hazards, development of strategies to resolve challenges, and supervision visits to monitor adherence to environmental standards and regulations. ProVIC also conducted trainings at the start of the project to build capacity of HTC, PMTCT, and care and support service providers in biomedical waste management, instilling best practices from the onset. Over the course of the project, ProVIC continually provided quality assurance and necessary materials, equipment, and assistance to support sound handling of biomedical waste in all supported sites. ProVIC and its partners also regularly reviewed adherence to the Environmental Mitigation and Monitoring Plan (EMMP) during integrated supervision visits to each site. ProVIC and partner staff conducted supervision visits using a checklist to monitor and verify the quality of all activities, including a specific section devoted to EMMP activities in line with national norms and USAID’s health care waste management guidelines. Through these visits, ProVIC ensured that service providers in supported sites followed their plans and respected agreed-upon division of roles and responsibilities.

As a follow-up to these visits, ProVIC provided targeted biomedical waste management training for service providers throughout ProVIC sites. In addition, ProVIC offered biomedical waste management training as one segment of the integrated HIV trainings, such as the PMTCT training in Year 4 that was given in five provinces, in line with the Strategic Pivot. Over the course of the project, a total of 1,609 service providers (social workers, doctors, nurses, laboratory technicians, and community workers) received training in various modules of waste management, including biosafety, post-exposure accident management, waste incineration and disposal procedures, and maintenance of sterile conditions during testing.

ProVIC also directly invested in EMMP systems in several supported sites during the project, namely through the installation and renovation of incinerators, destruction sites for managing biomedical waste, and fences to prevent people, specifically neighboring children, from wandering into the sites and risking exposure. ProVIC also continued to supply adequate quantities of required commodities to ensure proper handling, sorting, collection, transportation, and disposal of biomedical waste.

Annex C. Maps

Please see attached.

Annex D. Submitted deliverables

Quarter/Year Deliverable Submitted Year 1 – FY2010 FY2010 Annual Work Plan Q1 FY2010 Revised: Q2 FY2010 Performance Monitoring and Evaluation Plan (PMEP) Q1 FY2010 Sub-grants/Grants Under Contract (GUC) Management Plan Q1 FY2010 Revised: Q4 FY2010 FY2010 Q1 Financial Report Q2 FY2010 FY2010 Mid-Year Report Q2 FY2010 Revised PMEP Q2 FY2010 FY2010 Q2 Financial Report Q3 FY2010 FY2010 PEPFAR Semi-Annual Program Results (SAPR) Q3 FY2010 FY2010 Q3 Technical Report Q4 FY2010 FY2010 Q3 Financial Report Q4 FY2010 Branding Strategy and Marking Plan Q4 FY2010 Revised: Q4 FY2011 FY2010 Annual Report Q1 FY2011 FY2010 PEPFAR Annual Program Results (APR) Q1 FY2011 FY2010 Q4 Financial Report Q1 FY2011 Technical Assistance Report – Administrative Start-up Q1 FY2010 Martha Larson (Chemonics), Lydia Nelson (Chemonics), Melody Chuang (Chemonics) Technical Assistance Report – Technical Start-up Q1 FY2010 Scott Pflueger (PATH), Kathryn Goldman (Chemonics), Valerie Hovetter Technical Assistance Report – PMEP Development Q1 FY2010 Margaret Waithatka (PATH) and Jenina Khayali (Chemonics) Technical Assistance Report – FY2010 Q2 Supervisory Visit Q3 FY2010 Nathalie Albrow (PATH) and Kathryn Goldman (Chemonics) Technical Assistance Report – FY2010 Q2 ProVIC Partners Retreat Q3 FY2010 Ados May (IHAA) Technical Assistance Report – Commodities Q4 FY2010 Frank Biayi (PATH) Technical Assistance Report – Community Engagement Strategy Q4 FY2010 Aline Sylvie Pawele (IHAA) Technical Assistance Report – Champion Community Strategy Q4 FY2010 Rija Lalanirina Fanomeza (Chemonics) Technical Assistance Report – HTC and Family Planning Q4 FY2010 Dorcas Muteteke (Chemonics) Technical Assistance Report – Gender and GBV Q4 FY2010 Monique Widyono (PATH)

Quarter/Year Deliverable Submitted Technical Assistance Report – Work Plan & Annual Report Q1 FY2011 Development Nathalie Albrow (PATH), Kathryn Goldman (Chemonics), Simon Mollison (IHAA), Gabirelle Bielen (EGPAF) Technical Assistance Report – Monitoring and Evaluation Q1 FY2011 Anh Thu Hoang (PATH) Year 2 – FY2011 FY2011 Annual Work Plan Q1 FY2011 FY2011 Q1 Technical Report Q2 FY2011 FY2011 Q1 Financial Report Q2 FY2011 FY2011 Mid-Year Report Q2 FY2011 FY2011 PEPFAR Semi-Annual Program Results (SAPR) Q3 FY2011 FY2011 Q2 Financial Report Q3 FY2011 FY2011 Q3 Technical Report Q4 FY2011 FY2011 Q3 Financial Report Q4 FY2011 Revised PMEP Q4 FY2011 FY2011 Annual Report Q1 FY2012 FY2011 PEPFAR Annual Program Results (APR) Q1 FY2012 FY2011 Q4 Financial Report Q1 FY2012 Technical Assistance Report – PMTCT and Continuum of Care Q1 FY2011 Dr. Martha Mukaminega (EGPAF) Technical Assistance Report – ToT on Baseline Assessments of CCs Q1 FY2011 Anh Thu Hoang (PATH) Technical Assistance Report – ToT on Champion Community Q2 FY2011 Approach Dr. Rija Fanomeza (Chemonics) Technical Assistance Report – Health Systems Q3 FY2011 Dr. Jean Kabwau (PNMLS) Technical Assistance Report – Child-to-Child Manual and Training Q3 FY2011 Grazyna Bonati (IHAA) Technical Assistance Report – PMTCT, ART Treatment, Infant Q3 FY2011 Feeding Mitterand Katabuka (EGPAF) Technical Assistance Report – Finance & Grants Management Q3 FY2011 Shola Ajibola (PATH) Technical Assistance Report – PATH Orientation for new COP Q4 FY2011 Trad Hatton (PATH) Technical Assistance Report – Finance and Administration Q4 FY2011 Jean Ntumba (Chemonics) Technical Assistance Report – USAID Family Planning Workshop Q4 FY2011 Jolie Mamwezi Technical Assistance Report – Grants Management Support Q4 FY2011 Nefra Faltas (PATH) Technical Assistance Report – Procurement, Logistics & FOGS Q4 FY2011 Armand Utshudi (PATH)

Quarter/Year Deliverable Submitted Technical Assistance Report – Procurement, Logistics & FOGS Q4 FY2011 Armand Utshudi (PATH) Technical Assistance Report – Child Protection Framework Q4 FY2011 Sian Long (PATH) Technical Assistance Report – Care & Support and HSS Q4 FY2011 Simon Mollison (IHAA) Technical Assistance Report – Care & Support and HSS Q4 FY2011 Siobhan O’Dowd (IHAA) Technical Assistance Report – Data Quality Assessment Q1 FY2012 Anh Thu Hoang (PATH) Technical Assistance Report – Financial Compliance Q1 FY2012 Ousmane Amadou Sy (IHAA) and Aliene Badou Sow (IHAA) Technical Assistance Report – M&E Database Training Q1 FY2012 Karti Subramanian (PATH) Technical Assistance Report – Finance and Administration Q1 FY2012 Jean Ntumba (Chemonics) Technical Assistance Report – Capacity Building Strategy & Work Q1 FY2012 Plan Aline Sylvie Pawele (IHAA) Technical Assistance Report – Year 3 Supervisory Visit and Work Q1 FY2012 Plan Martha Larson (Chemonics) Year 3 – FY2012 FY2012 Annual Work Plan Q1 FY2012 Revised: Q4 FY2012 FY2012 Q1 Technical Report Q2 FY2012 FY2012 Q1 Financial Report Q2 FY2012 FY2012 Mid-Year Report Q3 FY2012 Revised: Q3 FY2012 FY2012 Q2 Financial Report Q3 FY2012 Revised PMEP Q3 FY2012 FY2012 PEPFAR Semi-Annual Program Results (SAPR) Q3 FY2012 FY2012 Q3 Technical Report Q4 FY2012 FY2012 Q3 Financial Report Q4 FY2012 FY2012 Annual Report Q1 FY2013 Revised: Q2 FY2013 FY2012 PEPFAR Annual Program Results (APR) Q1 FY2013 FY2012 Q4 Financial Report Q1 FY2013 Technical Assistance Report – Security Assessment of ProVIC Offices Q1 FY2012 Christina Johnson (Chemonics) Technical Assistance Report – 42nd Union Conference on Lung Health Q1 FY2012 Freddy Salumu Mafuta (PNLS) Technical Assistance Report – Program Supervision Q1 FY2012 Matthew Breman (Chemonics)

Quarter/Year Deliverable Submitted Technical Assistance Report – Bi-annual M&E monitoring and Q2 FY2012 support Anh Thu Hoang (PATH) Technical Assistance Report – Workshop on HIV Prevention among Q2 FY2012 MSM Georges Ntumba and Voulu Makwalebi Technical Assistance Report – Referral System Learning Exchange Q3 FY2012 Visit Zambite Elysé (IHAA), Kabwau Jean (PNMLS), and Hilaire Mbwolie (PSSP) Technical Assistance Report – Nutritional Management of PLWHA Q3 FY2012 Paluku Bahwere (IHAA) Technical Assistance Report – Program Supervision Q3 FY2012 Matthew Breman (Chemonics) Technical Assistance Report – Child-to-Child Manual Updates and Q3 FY2012 ToT Amandine Bollinger (IHAA) Technical Assistance Report – Sustainability of Champion Q3 FY2012 Communities Vololoniaina Razaka (Chemonics) Technical Assistance Report –Gender/GBV Integration Q3 FY2012 Elizabeth Rowley (PATH) Technical Assistance Report – XIX International AIDS Conference Q4 FY2012 Voulu Makawelebi Technical Assistance Report – Bi-annual M&E monitoring and Q4 FY2012 support Anh Thu Hoang (PATH) Technical Assistance Report – Mentor Mothers Learning Exchange Q4 FY2012 Visit Berthe Banzua Mbombo (EGPAF) Technical Assistance Report – Work Plan Workshop Q4 FY2012 Gabrielle Bielen (EGPAF) Technical Assistance Report – Work Plan Workshop Q4 FY2012 Simon Mollison (IHAA) Technical Assistance Report – Work Plan Workshop Q4 FY2012 Sujata Rana (PATH) Technical Assistance Report – Grants Management Support Q4 FY2012 Nefra Faltas (PATH) Technical Assistance Report – Finance and Administration TA Q4 FY2012 Younne Diallo (Chemonics) Technical Assistance Report – QuickBooks training Q4 FY2012 Ousmane Kere (IHAA) Technical Assistance Report – Work Plan Workshop & Bukavu Q1 FY2013 Operations Emily Gikow (Chemonics) Technical Assistance Report – Work Plan Workshop Q1 FY2013 Matthew Breman (Chemonics)

Quarter/Year Deliverable Submitted Technical Assistance Report – Documenting Success Stories Q1 FY2013 Melanie Coyne (IHAA) Year 4 – FY2013 FY2013 Annual Work Plan Q1 FY2013 Revised: Q4 FY2013 Revised PMEP Q1 FY2013 FY2013 Q1 Technical Report Q2 FY2013 FY2013 Q1 Financial Report Q2 FY2013 FY2013 Mid-Year Report Q3 FY2013 FY2013 Q2 Financial Report Q3 FY2013 FY2013 PEPFAR Semi-Annual Program Results (SAPR) Q3 FY2013 FY2013 Q3 Technical Report Q4 FY2013 Revised: Q1 FY2014 FY2013 Q3 Financial Report Q4 FY2013 Revised PMEP Q4 FY2013 FY2013 Annual Report Q1 FY2014 Revised: Q2 FY2014 FY2013 PEPFAR Annual Program Results (APR) Q1 FY2014 FY2013 Q4 Financial Report Q1 FY2014 Technical Assistance Report – Financial and Administrative Review Q2 FY2013 Younne Diallo (Chemonics) Technical Assistance Report – Risk Management Assessment Q2 FY2013 Peter Murphy (Chemonics) Technical Assistance Report – Work Plan and budgeting for PMTCT Q2 FY2013 Pivot Christina Kramer (Chemonics) Technical Assistance Report – Quality Improvement Collaboratives Q2 FY2013 Dr. Zakari Saley (URC) Technical Assistance Report – Work Plan & budgeting for PMTCT Q2 FY2013 Pivot Sujata Rana (PATH) Technical Assistance Report – Work Plan for PMTCT Pivot Q3 FY2013 Gabrielle Bielen (EGPAF) Technical Assistance Report – Grants Management Support Q3 FY2013 Nefra Faltas (PATH) Technical Assistance Report – PMTCT Collaborative Improvement Q3 FY2013 TA Dr. Zakari Saley (URC) Technical Assistance Report – Work Plan budgeting for PMTCT Pivot Q3 FY2013 Scott Pflueger (PATH) Technical Assistance Report – Administrative Support Q4 FY2013 Aurélie Attard Espinoza (Chemonics) Year 5 – FY2014

Quarter/Year Deliverable Submitted FY2014 Annual Work Plan Q1 FY2014 Revised: Q1 FY2014 FY2014 Q1 Technical Report Q2 FY2014 FY2014 Q1 Financial Report Q2 FY2014 FY2014 Mid-Year Report Q3 FY2014 FY2014 Q2 Financial Report Q3 FY2014 FY2014 PEPFAR Semi-Annual Program Results (SAPR) Q3 FY2014 FY2014 Q3 Technical Report Q4 FY2014 FY2014 Q3 Financial Report Q4 FY2014 FY2014 PEPFAR Annual Program Results (APR) Q1 FY2015 FY2014 Q4 Financial Report Q1 FY2015 Final Task Order Completion Report Q1 FY2015 Technical Assistance Report – Financial and Administrative Review Q1 FY2014 Tai Dieudonné (Chemonics) Technical Assistance Report – Project Supervision Q2 FY2014 Bridget Burke (Chemonics) Technical Assistance Report – Matadi Office Close-out Q2 FY2014 Tamara Coger (Chemonics) Technical Assistance Report – Grant Management Support Q3 FY2014 Davina Canagasabey (PATH) Technical Assistance Report – Kisangani and Kinshasa Office Close- Q3 FY2014 out Cassandre Dupont (Chemonics) Technical Assistance Report – Close-out Supervision Q3 FY2014 Emily Gikow (Chemonics) Technical Assistance Report – PMTCT-ART integration into MCH Q3 FY2014 Berthe Banzua (EGPAF) Technical Assistance Report – TA on PMTCT integration into MCH Q3 FY2014 Dr. Alexandre Boon (EGPAF) Technical Assistance Report – Project Documentation Q3 FY2014 Lisa Mueller Scott (PATH) Technical Assistance Report – Pediatric and Adult Care Learning Q3 FY2014 Exchange Mitterand Katabuka (EGPAF) Technical Assistance Report – Field Accounting Close-out Review Q3 FY2014 Mary Rose Tuba (Chemonics) Technical Assistance Report – Lubumbashi Office Close-out Q3 FY2014 Tamara Coger (Chemonics) Technical Assistance Report – Project Close-out Q4 FY2014 Bridget Burke (Chemonics) Technical Assistance Report – Close-out Supervision Q4 FY2014 Emily Gikow (Chemonics) Technical Assistance Report – Program Support Q4 FY2014 Yabsera Marcos (EGPAF)

Quarter/Year Deliverable Submitted Technical Assistance Report – IT Support Q1 FY2015 Eric Mauduit (PATH) Year 6 – FY2015 (Cost Extension) FY2015 Annual Work Plan (Cost Extension) Q1 FY2015 Revised: Q1 FY2015 Revised PMEP Q1 FY2015

DRC INTEGRATED

HIV/AIDS PROJECT

PROJET INTEGRE DE VIH/SIDA AU CONGO (PROVIC) ADDENDUM TO PROVIC FINAL REPORT – YEAR 6 ACTIVITIES

October 2014 through March 2015 Contract #GHH-I-00-07-00061-00, Order No. 03

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

TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... lxxxiv EXECUTIVE SUMMARY ...... lxxxvi SECTION I: PROGRESS BY TECHNICAL COMPONENT ...... 90 Intermediate Result 1: Continued access to comprehensive PMTCT and HIV prevention interventions for key populations ...... 90 Sub-IR 1.1: Access to comprehensive PMTCT services according to national norms in ProVIC-supported sites ...... 90 Sub-IR 1.2: Promotion and uptake of pediatric testing and counseling, and improvement in follow-up of mother-infant pairs ...... 98 Sub-IR 1.3: Undertaking of prevention strategies for key populations in target areas ...... 100 Intermediate Result 2: Improved access to adult and pediatric treatment ...... 104 Sub-IR 2.1: Maximizing access to ART ...... 104 Sub-IR 2.2: Maximizing the quality of care and ART services ...... 108 Intermediate Result 3: Health systems strengthening supported ...... 114 Sub-IR 3.1: Capacity of provincial government health systems supported ...... 114 Sub-IR 3.2: Strategic information systems at facility levels strengthened ...... 115 SECTION II. PROGRAM MANAGEMENT UPDATE ...... 118 Administration and finance ...... 118 Environmental monitoring and mitigation activities ...... 118

lxxxiii

ACRONYMS AND ABBREVIATIONS

AIDS acquired immune deficiency syndrome ANC antenatal care ART antiretroviral therapy ARV antiretroviral medication BMI body mass index CDC United States Centers for Disease Control and Prevention CSDT TB diagnostic and treatment centers CSW commercial sex workers CTX cotrimoxazole DATIM Data for Accountability, Transparency, and Impact Monitoring DBS dried blood spot DRC Democratic Republic of Congo E2A Evidence to Action EID early infant diagnosis EMMP Environmental Mitigation and Monitoring Plan FANTA III Food and Nutrition Technical Assistance III Project FY Fiscal Year GBV gender-based violence Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria HAART highly active antiretroviral therapy HEI HIV-exposed infants HIV human immunodeficiency virus HTC HIV testing and counseling IR Intermediate Result M&E monitoring and evaluation MER Monitoring, Evaluation, and Reporting MNCH maternal, newborn, and child health MOH Ministry of Health MSM men who have sex with men MUAC mid-upper arm circumference NACS nutrition assessment, counseling, and support NGO nongovernmental organization OGAC Office of the US Global AIDS Coordinator OVC orphans and vulnerable children PBF performance-based financing PCR polymerase chain reaction PEPFAR United States President’s Emergency Plan for AIDS Relief PITC provider-initiated testing and counseling PLHIV people living with HIV/AIDS PMTCT prevention of mother-to-child transmission of HIV PNLS Programme National de Lutte contre le SIDA (National HIV/AIDS Program) PNMLS Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (National Multi-Sectorial Program for the Fight against AIDS) PNSR Programme National de Santé de la Reproduction (National Reproductive Health Program) PRONANUT Programme National de Nutrition (Ministry of Health National Nutrition Department) ProVIC Projet Intégré de VIH/SIDA au Congo (Integrated HIV/AIDS Project) QA/QI quality assurance/quality improvement ReCos relais communautaires (community outreach volunteers) SCMS Supply Chain Management System SGBV sexual and gender-based violence

lxxxiv

SIMS Site Improvement through Monitoring System SMS short message service STI sexually transmitted infection TB tuberculosis TB/HIV TB/HIV co-infection USAID United States Agency for International Development

lxxxv

EXECUTIVE SUMMARY

October 2014 through March 2015 was a period of improving results as well significant transition for Projet Intégré de VIH/SIDA au Congo (ProVIC). As of March 2015, ProVIC’s cohort on ART has now grown to 6,752 with much of the increase associated with the full-rollout of Option B+ whereby all HIV+ pregnant women are initiated on ART, irrespective of CD4. Of these, 1,595 were newly enrolled during the reporting period including 791 newly enrolled in Katanga, 254 in Kinshasa and 256 newly enrolled in Ituri province where ProVIC is presently scaling up clinical services to reach high-risk populations associated with artisanal mining and sex work around the Kilo Moto gold mine.

The period was highlighted by a shift in health facilities where ProVIC offers a comprehensive package of care, treatment, and support services. At the recommendation of USAID and with a goal of improving cost-efficiencies, this transition of sites was marked by the closure of ProVIC’s activities in 18 facilities in Kongo Central (Bas-Congo) and the scale-up of 25 additional health facilities in Ituri Province near Bunia. Another key highlight of the period was important enhancement in how ProVIC collects and reports on data, including the Data for Accountability, Transparency, and Impact Monitoring (DATIM) system, and the integration of Tier.net as an antiretroviral therapy (ART) patient monitoring tool.

ProVIC is also undergoing a significant administrative change from support under the AIDSTAR contract mechanism to the Evidence to Action (E2A) cooperative agreement mechanism. As such, this report is the last ProVIC progress report under the AIDSTAR mechanism, as activities under AIDSTAR ended in Quarter 2 (Q2). Note that all targets and results in this final technical AIDSTAR report are associated with the six-month period of Q1 and Q2 of Fiscal Year (FY) 2015 and not the entire FY2015. From Q3 until the end of FY2015, ProVIC will be funded by the E2A project and targets and results will be reported accordingly through the E2A mechanism.

Key operational highlights of the period October 2014 through March 2015 are summarized below.

Kongo Central (Formerly Bas Congo) closure In December 2014, ProVIC successfully completed its planned withdrawal from Kongo Central, as required by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) due to the relatively low prevalence (0.2%) of HIV in the province. To ensure maximum transparency and predictability for beneficiaries, authorities, and stakeholders, this withdrawal was jointly planned, coordinated, and implemented with national, provincial, and local stakeholders over several months. Implementation included a joint site assessment with the Ministry of Health (MOH), including the pre-positioning of medications, supplies, and commodities as buffer stock while new Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) partners transitioned into their responsibility. The completion of transfer activities was marked formally in December 2014 when a public meeting was convened by the Kongo Central Provincial Minister of Health and the Kongo Central Provincial Assembly. During the meeting, these politico/administrative authorities recognized the significant contributions of the United States Agency for International Development (USAID) via ProVIC and formally transferred responsibility for ongoing care from ProVIC to the Global Fund partners.

Bunia/Ituri scale-up With the closure of activities in Kongo Central, and in line with PEPFAR objectives to improve cost efficiencies by focusing on high-prevalence health zones and high-volume health facilities, ProVIC resources were shifted to scale up around Bunia in Ituri Province, where the HIV prevalence rate is 2.7%, according to the Programme National de Lutte contre le SIDA (PNLS). Figures 1 and 2 below show the provincial distribution of health zones and health facilities (central/hub and peripheral/spoke sites) supported by ProVIC in Q1 and Q2 respectively. In Q1 of FY2015, after receiving a formal request from the MOH to intervene in Ituri, USAID and ProVIC began official discussions with the

lxxxvi

PNLS on the expansion of ProVIC activities in Ituri. Agreement was reached between the PNLS, Global Fund, and USAID that ProVIC would scale up from seven sites around the provincial capital of Bunia to a new total of 32 sites. These additional 25 sites cover high-risk health zones in and around the massive gold mining concession known as Kilo Moto. Support to these health zones will address critical drivers of the epidemic which make Ituri a key “hot spot” in the fight against HIV in the Democratic Republic of Congo (DRC). Ituri, which borders Uganda (HIV prevalence 7.2%), is characterized by tens of thousands of highly mobile artisanal gold miners, commercial sex workers, and truck drivers who are active in the gold mining fields.

Figure 1. Distribution of ProVIC-supported health zones and facilities in Q1 FY2015.

35 29 30

25

20

15 13 10 10 11 10 10 6 4 5 5 5 5 3 3 3 2 2 1 2 0 Haut-Katanga Tshopo Haut-Lomami Kinshasa Ituri Kongo Central

Health Zones Health Facilities Health Facilities (hub sites) (spoke sites)

Figure 2. Distribution of ProVIC-supported health zones and facilities in Q2 FY2015.

35 29 30 27 25

20

15 10 10 11 10 10 6 4 5 5 5 3 3 2 2 3 0 Haut-Katanga Tshopo Haut-Lomami Kinshasa Ituri

Health Zones Health Facilities Health Facilities (hub sites) (spoke sites)

Improving patient management and tracking via Tier.net ProVIC significantly upgraded its capacity in patient management in Q1 and Q2 by integrating the Tier.net tool across ProVIC-supported sites, which included installing Tier.net and training providers in more than 100 health facilities in Kinshasa, Katanga, and Province Orientale. The Tier.net tool has changed the way ProVIC collects and analyzes data on its beneficiary cohort, as the tool manages individual patient data which are then aggregated for analysis at the site, health zone, provincial, and

lxxxvii

national levels. Since the PNLS is using this tool nationally, ProVIC’s Tier.net data are standardized and can be aggregated with data from other non-ProVIC and non-PEPFAR projects and facilities. Going forward, ProVIC will place considerable emphasis on working with health zone- and site-level health care providers to use Tier.net data in their analysis and planning.

Shifting the data collection mechanism to the DATIM system In February 2015, USAID introduced the United States government’s DATIM database in the DRC by training ProVIC and other United States government partners as part of the PEPFAR/Office of the US Global AIDS Coordinator (OGAC) global rollout of DATIM. DATIM centralizes data for improved transparency, monitoring, and analysis, particularly aggregated site- and health zone-level data. ProVIC quickly adopted DATIM by cascading training to monitoring and evaluation and other technical officers across ProVIC’s regional offices and rolling out the database across ProVIC offices. ProVIC populated DATIM with its data going back to October 2014 so that analysis can be completed for the entire fiscal year, as requested by PEPFAR/OGAC. Although there may be kinks to work out with such a significant change in the reporting process over a short period of time, ProVIC is now aligned with DATIM and its site-level data can be analyzed directly by PEPFAR/OGAC/USAID staff in the DRC or in the United States.

Key technical area highlights of the October 2014 through March 2015 period are summarized below.

Prevention of mother-to-child transmission of HIV‡‡‡‡‡

During the first six months of FY2015, ProVIC remained one of the main supporters of prevention of mother-to-child transmission of HIV (PMTCT) services offered in the DRC in line with MOH guidelines, the World Health Organization’s Consolidated Guidelines, and the 2015 PEPFAR Technical Considerations. ProVIC’s approach took into account the four pillars of PMTCT: primary HIV prevention; family planning; treatment and prophylaxis during pregnancy and while breastfeeding; and ongoing monitoring, treatment, care, and support for women and their families. The majority of ProVIC’s beneficiaries receive services through the PMTCT platform, following ProVIC’s acceleration toward PMTCT in 2012 and the Strategic Pivot in 2013. In Q1 and Q2, ProVIC tested 32,946 pregnant women, of whom 654 tested HIV positive (2% PMTCT positivity rate) and 525 (84%) were pregnant women newly identified at health clinics through the PMTCT entry point. Of the 654 HIV-positive pregnant women, 628 received antiretroviral medications (ARVs) for PMTCT (96%).

HIV testing and counseling

The results of ProVIC’s HIV testing and counseling activities reflect counseling provided at the health facility level to pregnant women and their families and patients identified through provider-initiated testing and counseling, as well as counseling specifically targeting key populations of commercial sex workers (CSW), men who have sex with men (MSM), and injection drug users, and priority populations of truck drivers, miners, and fishermen. In total, 50,860 individuals were tested for HIV in Q1 and Q2. Of those tested, 2,332 individuals tested positive, a seropositivity rate of 4.5%. Seropositivity rates for key and priority populations are listed below: • CSW: 11.5% of 339 individuals tested in Haut-Katanga, Haut-Lomami, Ituri, and Tshopo.

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

lxxxviii

• MSM: 7.3% of 274 individuals tested in Haut-Katanga and Kinshasa. • Truck drivers: 11% of 119 individuals tested in Haut-Katanga, Haut-Lomami, Ituri, and Tshopo. • Miners: 12% of 218 individuals tested in Haut-Katanga, Haut-Lomami, Ituri, and Tshopo.

Care, support, and treatment

ProVIC’s current ART cohort (as of March 31, 2015) comprises 6,752 people living with HIV/AIDS (PLHIV), including 1,595 PLHIV—1,480 adults and 115 children—newly enrolled in ART in Q1 and Q2 of FY2015. Of the 6,752 PLHIV currently on ART, 6,626 (98%) received at least one clinical assessment, CD4 count, or viral load test, and of these, 6,231 (94%) were screened for tuberculosis. In addition, 733 clinically malnourished PLHIV were provided with therapeutic and supplementary food.

In summary, Q1 and Q2 results represent a consistent extension of the comprehensive HIV/AIDS services offered in ProVIC sites. ProVIC anticipates meeting its established targets across both the AIDSTAR and E2A funding mechanisms that will support the project in FY2015.

lxxxix

SECTION I: PROGRESS BY TECHNICAL COMPONENT

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

Sub-IR 1.1: Access to comprehensive PMTCT services according to national norms in ProVIC-supported sites Activities and achievements Activity 1: Access to comprehensive PMTCT services (including Option B+) in ProVIC sites, according to national norms. During the first two quarters of Fiscal Year (FY) 2015, Projet Intégré de VIH/SIDA au Congo (ProVIC) tested and informed 32,946 pregnant women of their HIV status (includes known positives at entry, which reflects a 64% achievement against ProVIC’s planned target of 51,294). ProVIC’s underachievement in this area is due to two major challenges. The first was the ending of project activities in Kongo Central (Bas-Congo) in December 2014, so health facilities carried out technical activities for only two out of three months in Quarter 1 (Q1). Secondly, while ProVIC expanded its presence in Ituri, the 25 new health facilities carried out technical activities only for the last month of Q2. Table 1 below provides an overview of the cascade of prevention of mother-to-child transmission of HIV (PMTCT) services in Q1 and Q2 of FY2015.

Table 1. PMTCT cascade in Q1 and Q2 FY2015, by province. Kongo Haut- Haut- Central Katanga Lomami Kinshasa Ituri Tshopo Total Pregnant women with known HIV status (includes women who were 2,198 12,630 3,221 8,436 3,189 3,272 32,946 tested for HIV and received their results) and known positives at entry Known positives at entry 8 58 8 50 2 3 129 New positives identified 35 265 22 88 67 48 525 Total known positives 43 323 30 138 69 51 654 Seropositivity 2% 2.6% 0.9% 1.6% 2.2% 1.6% 2% Known HIV-positive pregnant 628 women who received antiretroviral 42 314 24 136 67 45 (96%) medications HIV-positive women newly initiated 19 272 23 94 67 44 519 on treatment during pregnancy HIV-positive women already on 2 42 1 42 0 1 88 treatment at beginning of pregnancy HIV-positive women who received maternal zidovudine (prophylaxis 21 0 0 0 0 0 21 component of Option A)

Among the 32,946 pregnant women who know their status, 28,209 were tested at antenatal care (ANC) visits (86%) and 4,487 during labor and delivery (14%). A total of 654 tested HIV positive (2% seropositivity rate), of whom 525 were newly identified as positive and 129 women were known positive at entry. Seropositivity rates through the PMTCT entry point by province are as follows: Haut-Katanga, 2.6%; Ituri, 2.2%; Kongo Central, 2.0%; Tshopo, 1.6%; Kinshasa, 1.6%; and Haut-Lomami, 1.0%.

90

In all, 628 of 654 (96%) HIV-positive pregnant women received antiretroviral medications (ARVs) to reduce the risk of mother-to-child transmission of HIV during pregnancy and delivery. The proportion of HIV-positive pregnant women on ARVs (96%) is an impressive achievement given the slow start-up of activities in the 25 new PMTCT sites in Ituri, and reflects ProVIC’s intensive coaching of service providers in these new facilities and the contribution of Mentor Mothers in encouraging women to receive ARVs.

Among the 628 receiving ARVs, 21 HIV-positive pregnant women in Kongo Central received maternal zidovudine (the prophylaxis component of Option A) during pregnancy and delivery in Q1, and 607 HIV- positive pregnant women were placed on lifelong antiretroviral therapy (ART, including Option B+). Among the 607 placed on lifelong ART, 519 (87%) were newly initiated on ART and 88 (13%) were already on treatment. ProVIC also noted that among the 607 on lifelong ART, 472 were on TDF+3TC+EFV, 127 were on AZT+3TC+NVP, and eight were on AZT+3TC+EFV.§§§§§

ProVIC’s PMTCT package was aligned with Option B+, as adopted by the Democratic Republic of Congo (DRC), and included HIV testing for pregnant and breastfeeding women and members of their family, provision of ARVs for HIV-positive people in accordance with national guidelines, and provision of essential care and support. ProVIC, under the leadership of the Programme National de Lutte contre le SIDA (PNLS), conducted a needs assessment (using a tool from the Office of the US Global AIDS Coordinator/OGAC) in health facilities implementing Option A to collect challenges to be adressed before rolling out Option B+. The main challenges noted included increasing providers’ knowledge of Option B+ guidelines and their ability to correctly utilize commodity management tools, and improving availability of data collection tools. To address these challenges, ProVIC provided training on how to more accurately estimate monthly consumption of medications and monitor stock levels, and technical assistance on Option B+ protocols. Following the identification of challenges, ProVIC and the PNLS developed an Option B+ scale-up plan for Kinshasa and Province Orientale.

The first step was training providers to address weaknesses identifed during the needs assessment. The training was carried out over five days, in which two days were dedicated to building the capacity of health zone management teams to supervise health care providers implementing Option B+. The remaining three days were focused on training providers on Option B+ guidelines, including norms for ensuring rapid test quality; involvment of male partners and other family members; aspects of maternal and child health and family planning, with emphasis on young women; and management of commodities. At the end of the training program, 141 providers who work primarily in maternal, newborn, and child health (MNCH), pediatrics, and out- and inpatient services were able to offer Option B+ services, and 22 health zone management teams were trained on monitoring Option B+ activities. ProVIC is now implementing Option B+ in all 106 project-supported facilties.

The second step concerned the allocation of commodities and data collection tools in the health facilities. The ProVIC PMTCT team, in collaboration with the logistics team, developed a forecasting tool to ensure the availability of drugs and commodities in health facilities and to avoid stockouts. Initially, health facilities had supplies to cover three months, allowing time for providers to master basic supply management practices. ProVIC also printed and distributed data collection tools for six months to all project-supported health facilities.

§§§§§ TDF+3TC+EFV: tenofovir, lamivudine, and efavirenz; AZT+3TC+NVP: zidovudine, lamivudine, and nevirapine; AZT+3TC+EFV: zidovudine, lamivudine, and efavirenz.

91

To guarantee retention and improve tracking of mother-infant pairs, ProVIC extended the Mentor Mother approach to all project-supported health facilities where more than ten people living with HIV/AIDS (PLHIV) were receiving services. The Mentor Mother package of activities includes use of a tracking tool and home visits to track those lost to follow-up, encourage adherence to the calendar for early infant diagnosis (EID), and promote HIV testing for other children and male partners of HIV-positive pregnant women.

ProVIC continued to emphasize each pillar of the comprehensive PMTCT approach, as described below.

Pillar 1: Primary HIV prevention. As part of the PMTCT package, provider-initiated testing and counseling (PITC) services were offered to all pregnant/breastfeeding women, their children, and male partners at all ANC, childbirth, postpartum, and pediatric care settings. ProVIC also encouraged service providers to promote couples and male partner testing using a number of strategies, which included use of invitation letters given to pregnant women for their partners, expansion of service hours for HIV testing to accommodate work schedules, testing of male partners who accompany pregnant women during delivery, and through Mentor Mothers.

Job aids and registers were provided by ProVIC to help health care providers document patients and results in order to ensure the quality of HIV counseling and rapid tests, and to prevent reporting of false results. In addition, ProVIC sites participated in quarterly external laboratory quality control checks under PNLS leadership. At the end of Q2, 53 health facilities underwent laboratory quality checks and 25 passed the test (47%), showing that the quality of laboratory testing at these 25 sites is certified by the PNLS. Mobility of trained laboratory technicians is the primary reason some facilities did not pass the test. For those facilities, ProVIC will carry out more frequent supportive supervision sessions, in conjunction with the PNLS. ProVIC also provided mentorship to service providers to correctly complete forms and records.

Once tested, HIV-negative individuals were provided with a prevention counseling package, which included planning for risk reduction, education on consistent and correct condom use, condom negotiation skills, and the importance of retesting after three months. HIV-positive individuals were provided with the Positive Health, Dignity, and Prevention package. After clinical services, all tested clients were linked to community-based organizations—HIV-negative individuals continued to receive messaging on HIV and HIV-positive individuals were linked to peer support groups which helped provide psychosocial care services and ensure retention in treatment and clinical care programs.

As a result of training and mentorship provided to service providers on PITC, ProVIC observed a general increase in the numbers of male partners and couples tested for HIV in project-supported health facilities. The figure below compares HIV testing rates for male partners and couples in Q1 and Q2 of FY2014 and Q1 and Q2 of FY2015 in Tshopo and Ituri Provinces.

Figure 3. Percentage of male partners and couples tested in Tshopo and Ituri Provinces in Q1 and Q2 of FY2014 and FY2015.

92

60% 53% 50%

40% 34%

30%

20% 16% Q1&Q2 FY2014 10% Q1&Q2 FY2015 10% 2.7% 3.4% 0% Percentage of male Percentage of male Percentage of HIV-positive partners tested partners of HIV-positive couples tested pregnant and breastfeeding women tested

As shown, the percentage of male partners of pregnant and breastfeeding women tested in FY2015 was higher than in FY2014: 1,051 male partners of 6,461 women (16%) were tested in FY2015 as compared to 319 male partners of 3,181 (10%) tested in FY2014. The percentage of male partners of HIV-positive pregnant and breastfeeding women was similarly higher in FY2015 than in FY2014: 63 male partners of 120 HIV-positive women (53%) tested in FY2015 and only 21 male partners of 61 HIV-positive women (34%) tested in FY2014—as was the percentage of HIV-positive couples tested in FY2015 versus FY2014. These increases in testing rates in FY2015 can be attributed to the activities of Mentor Mothers, as they encouraged participation and testing of male partners of women receiving PMTCT services.

Pillar 2: Integration of PMTCT and family planning. ProVIC advised service providers to use all available opportunities, such as clinic visits and educational sessions, to provide women and their male partners with family planning counseling and services. These services include counseling on exclusive breastfeeding during the first six months of the postpartum period, the lactational amenorrhea method, and modern contraceptives. Service providers were also encouraged to provide safe pregnancy counseling for HIV-positive women who want to have children. Job aids (developed by ProVIC) were given to service providers to guide them in offering family planning services in accordance with national norms.

During the first two quarters of FY2015, 32% (21 of 66) of HIV-positive mothers were started on modern contraceptive methods, which is higher than the national rate (20%) as reported in the 2013-2014 Demographic and Health Survey for the DRC. ProVIC will strengthen family planning services in Q3 and Q4 of FY2015 as part of the project’s efforts to enhance reproductive and MNCH services during the Evidence to Action (E2A) extension.

93

Pillar 3: Provision of ART for pregnant and breastfeeding women and infant prophylaxis. As a reference for service providers, ProVIC developed an integrated MNCH/PMTCT/ART poster (based on a model adapted from the Elizabeth Glaser Pediatric AIDS Foundation in Lesotho), which details all tasks to be performed for pregnant women, their babies, and male partners in various MNCH settings (ANC, delivery, postnatal care, and under-five care). ProVIC also printed and provided health facilities with standard protocols for identifying and tracking pregnant or breastfeeding women and HIV- exposed infants (HEI) who miss appointments or are transferred to another site—ProVIC provided technical assistance to service providers to explain standard protocols.

In addition, ProVIC highlighted best practices and strategies to emphasize joint mother-infant pairs follow-up to support adherence to and retention in ART. Practices and strategies include distribution of Mother and Baby Packs, which contain ARVs (TDF/3TC/EFV), cotrimoxazole (CTX), condoms, and infant nevirapine; decentralization of ART delivery to Integrated MNCH/PMTCT/ART poster. spoke (peripheral) health facilities and task- sharing to allow nurses to initiate individuals on ART; monthly convenings of facility- and community-based service providers to monitor the retention of HIV-positive pregnant and breastfeeding women on treatment regimens and to strengthen tracking mechanisms; joint mother-infant postnatal visits; and use of longitudinal registers and cohort monitoring organized by ART initiation date for mothers and birth month for HEI to facilitate retention monitoring.

The introduction of the Mentor Mother approach has resulted in an increase in the uptake of ARVs and adherence to PMTCT treatment regimens. Figure 4 below provides a comparison of the number of HIV- positive women retained in ART three months after initiation in 2013, 2014, and 2015. Retention rates increased dramatically following the introduction of the Mentor Mother approach, from 47% in FY2013 to 89% in FY2014 and 97% in FY2015.

Figure 4. Comparison of retention rates of HIV-positive women on ART in Haut-Katanga, FY2013–FY2015.

94

35 97% 100% 89% Introduction of 31 30 90% 30 Mentor Mother 28 approach 80% 25 25 70% 60% 20 19 Number of 50% HIV-positive 15 47% women 40% 10 9 30% 20% 5 10% 0 0% January 2013 January 2014 January 2015

Initiated on ART Retained on ART after 3 months Percentage

Pillar 4: Essential care for HIV-positive women and children in PMTCT programs. ProVIC ensured that HIV-positive pregnant and breastfeeding women benefited from the essential care and support package, which includes provision of CTX prophylaxis, family planning, gender-based violence (GBV), HIV/TB (tuberculosis) co-infection, clinical and laboratory monitoring, screening and treatment for opportunistic infections and sexually transmitted infections (STIs), nutritional evaluation and treatment, and psychosocial support through Mentor Mothers and self-help groups for PLHIV. The table below documents the number of HIV-positive women in Kinshasa who received various care services in Q1 and Q2 of FY2015.

Table 2. Number and percentage of HIV-positive women in Kinshasa who received care and support services in Q1 and Q2 FY2015. STIs NACS GBV TB CTX ART Number of HIV-positive women who received 119 130 135 138 138 138 care services Number of HIV-positive women eligible for care 138 138 138 138 138 138 Percentage of HIV-positive women who received 86% 94% 98% 100% 100% 100% care services NACS: nutrition assessment, counseling, and support.

As noted in the table, 100% of the eligible HIV-positive women in project-supported facilities in Kinshasa received CTX prophylaxis and ART and were screened for TB. All 135 women screened for GBV received negative results, and only two of the 119 women screened for STIs received positive results; these women and their partners received appropriate treatment. Additional results and descriptions of ProVIC’s care and support activities are described in Sub-IR 2.2.

Activity 2: Extend/maintain innovative approaches to improve the quality of PMTCT services for pregnant women and their families.

95

Mentor Mother approach. Mentor Mother activities continued at 22 ProVIC-supported health facilities, and ProVIC’s PMTCT team provided coaching to ensure the high quality of this intervention to support the continuum of care for HIV-positive women and their families. To continue improving retention and joint follow-up of mother- baby pairs, ProVIC carried out refresher trainings for 72 established Mentor Mothers and 38 new Mentor Mothers, focused in particular on strategies to retain women in treatment and care regimens and reduce those lost to follow-up. The ProVIC team also held quarterly working sessions in each health Mentor Mothers sharing experiences during a zone with health zone management teams, Mentor meeting. Mothers, and service providers. These working sessions served as a forum for experience-sharing and lessons learned, and provided an opportunity to brainstorm solutions to challenges faced by Mentor Mothers and service providers. Health zone management teams appreciated these working sessions in particular because they contributed to the capacity-building of newer Mentor Mothers who were able to learn from experienced Mentor Mothers.

In addition, senior Mentor Mothers—those who have participated in the program for at least two years— will be organized into community-based adherence and support groups that will continue to support HIV- positive women whose infants have reached 18 months of age.

ProVIC had planned to extend the Mentor Mother approach to 30 additional health facilities in Q1 and Q2; however, this expansion was delayed to allow time for the PNLS to evaluate the Mentor Mother approach. The PNLS has now adopted this approach as part of the minimum package of activities offered by all health facilities and ProVIC will continue with the planned expansion in Q3.

Quality assurance/quality improvement (QA/QI) collaborative approach. At the end of Q2, ProVIC worked with the Applying Science to Strengthen and Improve Systems project to plan for expansion of the collaborative QA/QI approach. The QA/QI approach is currently implemented in 30 health facilities, with plans to extend the approach to an additional 28 facilities. A particular focus of this extension was improved monitoring of adherence and retention; since the implementation of Option B+ increased the number of HIV-positive pregnant women served, providers faced challenges documenting the number of women provided with adherence counseling. In addition, the QA/QI approach will focus on improvements in ART case management, EID, and the referral/counter-referral system. During Q1 and Q2, ProVIC continued to conduct coaching visits with the 28 health facilities currently implementing QA/QI activities, with health zone management teams participating in one QA/QI coaching visit per quarter.

Performance-based financing (PBF). ProVIC has ended implementation of the PBF approach at Kikimi Hospital Center as of the end of Q2 of FY2015. In collaboration with the Ministry of Health (MOH), ProVIC carried out a final technical and administrative evaluation of the PBF fixed obligation grant, and presented on ProVIC’s experience implementing the PBF model at a national-level meeting led by the General Secretary of Health. The MOH expressed satisfaction with the results presented by ProVIC and the project’s experience implementing PBF at Kikimi Hospital Center, especially as this was the first standalone PBF in the DRC that focused on HIV services. The MOH also stated a desire to expand the PBF model to other health facilities and health zones, and the General Secretary of Health recognized PBF as an efficacious method for strengthening health systems. Figure 5 below presents trends observed in quality improvement indicators while the PBF model was implemented in Kikimi Hospital Center.

96

Figure 5. Kikimi Hospital Center’s performance in quality improvement indicators from Q3 FY2013 through Q2 FY2015.

100% 95% 96% 100% 100% 88% 90% 90% 90% 100% 100% 78% 91% 80% 89% 80% 70% 67% 67% 68% 59% 60% 56% 63% 55% 60% 50% Performance 50% 38% 40% 30% 30%

20%

10%

0% Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 FY2013 FY2013 FY2014 FY2014 FY2014 FY2014 FY2015 FY2015 Streamlining patient registration Wait time reduction Lower cost of services

Progressive improvement can be seen in Kikimi’s performance across all three indicators over time. Patient wait times and registration/flow were the largest challenges. ProVIC observed that by streamlining patient registration and flow through the hospital center, through use of cues to better guide patients, wait times were also reduced. Reduction in the price of services (a decrease of 2-3%, depending on service type), an important outcome noted by the MOH, helped to increase the number of clients visiting the hospital.

Activity 3: Ensure coaching and mentorship for integrated PMTCT care, support, and treatment services offered through the health zones. In Q1 and Q2, ProVIC’s PMTCT team conducted two PMTCT review sessions. The first, organized one month after Option B+ training, focused on identifying challenges and responding to lingering questions from service providers as well as improving information reported in data collection tools. ProVIC noted that providers faced numerous challenges at first identifying and shifting all pregnant women on Option A to Option B+. The second review session was held three months after the first session and provided an opportunity for service providers, Mentor Mothers, and health zone management teams to share experiences and lessons learned. Health zone management teams appreciated this type of capacity- building/experience-sharing session as it provided an opportunity for service providers to improve their skills and knowledge as well as learn from their peers’ experiences.

ProVIC used trained interns as points of contact for health facilities (eight facilities per intern) to provide service providers with additional support and increase supportive supervision and mentorship opportunities. ProVIC also organized site vists at the end of Q1 and Q2 in which ProVIC and health zone management teams jointly assessed the quality of PMTCT and ART services offered at project-supported health facilities. ProVIC health facilities in Kinshasa also benefited from Site Improvement through Monitoring System (SIMS) visits conducted by the United States Agency for International Development (USAID); recommendations from the visits were incorporated into a performance improvement plan, and technical assistance and supportive supervision were provided by ProVIC’s technical team to improve the quality of service delivery.

97

Activity 4: Reinforce the capacity of the DRC government at multiple levels to provide comprehensive PMCTC services and treatment. ProVIC continued to participate in quarterly meetings held by the National PMTCT Working Group, the Maternal, Newborn, and Child Health Task Force, and National HIV/AIDS Strategic Plan Work Groups. ProVIC’s PMTCT team has been actively involved in discussions on updating Option B+ and pediatric HIV testing and counseling (HTC) policies, algorithms, and guidelines. In addition, ProVIC continued to contribute to the dissemination of national standards and guidelines on MNCH as well as standards related to adolescent and youth care, family planning, and care for victims of sexual and gender-based violence (SGBV) to all project-supported facilities. ProVIC also provided office supplies, fuel, and Internet fees to facilitate a number of workshops organized by the MOH.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Limited documentation of adherence follow-up • Disseminate job aids on adherence in each in the data collection tools. health facility. • Allocate more time on documentation and follow-up of adherence during mentorship sessions.

Sub-IR 1.2: Promotion and uptake of pediatric testing and counseling, and improvement in follow-up of mother-infant pairs Activities and achievements Activity 1: Reinforce the system of early infant testing and services. ProVIC focused on scaling up access to HIV virological testing (polymerase chain reaction [PCR] testing of dried blood spots [DBS] or plasma) for infants at 4 to 6 weeks of age and improving the turnaround time for results sent to caregivers of HEI. ProVIC held onsite technical assistance sessions on integrated EID (including sample collection, packaging, and tracking through final outcome) for all facility workers providing ANC, labor and delivery, postnatal, and under-five care. Emphasis was also placed on improving the quality and frequency of messaging delivered to caregivers on EID, EID services, and needed follow-ups for infants born to HIV-positive mothers. Phone calls, SMS messages, and home visits were emphasized as opportunities to remind mothers of follow-up care visits for infants for EID and initiation on CTX.

A total of 318 infants were tested for HIV within 12 months of birth and 222 exposed infants were started on CTX in the first two quarters of FY2015, 38% (120) of whom received a test within two months of birth and 62% (198) of whom received a test between 2 and 12 months of age. Results received from the national PNLS laboratory revealed five HIV-positive infants (1.6%), born to mothers who were not tested or on ARVs during pregnancy, and ProVIC followed up with service providers at the facilities in Kinshasa and Haut-Katanga to ensure that each infant was placed on ART. Cases of particular concern were pregnant women who came to the facility for delivery and were not on ARVs during their pregnancy. The table below provides an overview of ProVIC’s performance in EID in Q1 and Q2 of FY2015, by province.

Table 3. Cascade of EID services in Q1 and Q2 FY2015, by province. Kongo Haut- Haut- Central Katanga Lomami Kinshasa Ituri Tshopo Total Infants born to HIV-positive 10 127 1 125 40 15 318 women who received a

98

Kongo Haut- Haut- Central Katanga Lomami Kinshasa Ituri Tshopo Total virological HIV test within 12 months of birth Percentage of infants who received their first virological test 30% 39% 100% 39% 33% 27% 38% within two months of birth Percentage of infants who received their first virological HIV 70% 61% 0% 61% 68% 73% 62% test between 2 and 12 months of age Infants born to HIV-infected women started on CTX within 6 83 0 72 56 5 222 two months of birth Infants with a positive virological test result within 12 months of 0 4 0 1 0 0 5 birth

In Q1 and Q2, ProVIC encountered delays in obtaining results from DBS samples due to changes in laboratory locations, the installation of an extractor, and lack of reagents available through the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which prevented the national PNLS laboratory from carrying out analyses from December 2014 through March 2015. The PNLS laboratory has provided results from HIV DNA PCR for 67 DBS samples thus far. Of the 67 samples tested, four samples taken from children at 6 weeks of age were positive; these children have all been placed on treatment.

Emphasis was also placed on improving access to pediatric testing beyond EID. Providers were trained in Q1 and Q2 to offer universal opt-out PITC in all inpatient pediatric wards, malnutrition clinics, and TB clinics and to orphans and vulnerable children (OVC), older infants of HIV-positive pregnant and breastfeeding women or PLHIV, and siblings of HIV-infected children. Providers were also trained to invest in bi-directional referral mechanisms between OVC programs and HIV care centers to ensure that all children enrolled in OVC programs are able to access HIV testing and HIV-related services, and all HIV-infected and exposed children receive OVC support. Care providers used these entry points to identify HIV-positive children and link them to care and treatment services. In addition, ProVIC advocated to health zone management teams to hold adolescent clinic days (for 10–19 year olds) to improve adolescent adherence to care. Health zone management teams expressed interest in adolescent clinic days and discussions will be continued in Q3 and Q4.

Activity 2: Improve the clinical follow-up of HIV-exposed children, including provision of the essential care package to the newborn baby. ProVIC continued to work with service providers on follow-up of HEI through cessation of breastfeeding and ensure rapid referral of infected infants and children to treatment services. Job aids on EID and pediatric ARV guidelines were developed and distributed to service providers at onsite technical assistance sessions. ProVIC developed and promoted use of the child monitoring table (disaggregated by age and appointment dates for PCR and HIV rapid testing) to better track mother-infant pairs through all required tests and final diagnosis. Use of this tool in ProVIC-supported sites improved follow-up of mother-infant pairs and reduced those lost to follow-up, as captured in Table 3 above. During this reporting period, there was a national stockout of DBS kits for one month, so a second DNA PCR test was not done for some HIV-exposed children.

Challenges during the reporting period and proposed solutions

99

Challenges Proposed solutions Delay in receiving results from DNA PCR tests • Contract with a private DNA PCR laboratory from the national PNLS laboratory, making it when the national PNLS laboratory fails. difficult to track and follow up infected children. • Approach the PNLS about decentralizing DBS analysis for quicker return of results. Low uptake of HIV testing after the first DNA • Increase mentoring of service providers. PCR as recommended by the PNLS. • Provide technical assistance on use of the child monitoring tool.

Sub-IR 1.3: Undertaking of prevention strategies for key populations in target areas Activities and achievements Activity 1: Reinforce and expand access to prevention services for key populations and other vulnerable groups. In the first two quarters of FY2015, ProVIC reached 546 members from key populations with HIV prevention services—96 men who have sex with men (MSM) and 450 commercial sex workers (CSW)— reflecting a 28% achievement against ProVIC’s target for the first six months of FY2015. This low achievement in the number of individuals from key populations reached with prevention services is due to the decrease in the number of peer educators (from 40 to 10). In addition to reaching individuals with HIV awareness-raising activities, 764 members of key populations were tested for HIV: 387 CSW (50.6%), 359 MSM (46.9%), and 18 injection drug users (2.3%), of whom 72 were revealed to be HIV positive, a seropositivity rate of 9.4%. Table 4 below shows results for key populations tested, by province.

Table 4. Results of key populations tested by two partners in Q1 and Q2 FY2015. Individuals tested and their results Commercial sex workers Men who have sex with men Injection drug users Seropositivity Seropositivity Seropositivity Province Partner Negative Positive rate Negative Positive rate Negative Positive rate Haut- World 296 31 9.4% 19 1 5% 0 0 N/A Katanga Production Kinshasa St. Hilaire 51 9 15% 310 29 9% 16 2 11.11% Total 347 40 10.3% 329 30 8.3% 16 2 11.1%

HIV prevention services were led by MSM and CSW peer educators who carried out the following activities: • Promoted correct use of and distributed male and female condoms and water-based lubricants. • Provided counseling on low-risk sexual behaviors and practices and HIV. • Raised awareness of entry points for accessing testing and treatment services for STIs. • Encouraged individuals to be tested for HIV.

In addition to activities targeting key populations, relais communautaires (ReCos—community outreach volunteers) continued to reach out to priority populations, which included “other vulnerable populations,” such as CSW clients, uniformed services, and mobile populations of truck drivers and miners, through small group discussions, door-to-door sensitization, orientation to health facilities, and condom distribution. In Q1 and Q2, the majority of outreach was focused on truck drivers, miners, and clients of CSW, with a total of 481 priority populations reached with prevention messages.

100

Kinshasa. Key population peer educators worked under the supervision of health zone staff and St. Hilaire Health Center, an MSM-friendly health facility supported by ProVIC, to reach members of key populations with HIV prevention, testing, and care services. This close coordination with St. Hilaire allowed ProVIC to ensure a continuum of response for individuals who tested HIV positive, allowing for easier referrals to health facilities for clinical follow-up and treatment services and psychosocial support. St. Hilaire Health Center provided HIV and STI testing services for key populations, MSM in particular, as well as TB screening and family planning services.

Katanga. World Production is ProVIC’s main partner for carrying out HIV prevention services for key populations in Katanga. World Production used peer educators to raise awareness of HIV prevention methods and encouraged individuals to attend mobile HTC sessions carried out in Lubumbashi and Kasumbalesa. World Production also enlisted peer educators and health care providers from local ProVIC-supported health facilities to carry out HIV awareness-raising and prevention services at hotels frequented by CSW in order to better reach and facilitate access to services for CSW.

Province Orientale. ProVIC does not support any key population-specific health facilities or nongovernmental organizations (NGOs) in Orientale, but ReCos and peer educators from former ProVIC champion communities continued to actively disseminate HIV prevention messaging. ProVIC also provided support to the Programme Nationale Multi-Sectorielle de Lutte contre le SIDA (PNMLS) to carry out HIV sensitization events in Kisangani and Bunia on World AIDS Day.

Activity 2: Mobilize communities around ProVIC-supported health facilities with high prevalence rates to increase demand for and use of services, as well as involvement of male partners. In the first two quarters of FY2015, 26,137 members of the general population were reached with HIV prevention messaging (3,297 men and 22,840 women), with the majority of women reached through the PMTCT entry point (20,459).

ProVIC’s HIV and GBV prevention and family planning outreach in project-supported facilities focused on ensuring individuals were aware of and accessed prevention, care, and support services offered at health facilities. Outreach was generally targeted toward pregnant women and youth of reproductive age, but also focused on reaching male partners of pregnant women to encourage their involvement in and support of their partners’ adherence to PMTCT services. ProVIC accomplished expected objectives for this activity through advocacy and outreach efforts carried out by health care workers in project-supported facilities, and through community sensitization activities carried out by Mentor Mothers, ReCos, and peer educators in ProVIC health zones. Members of the general population were reached with the following: • Messaging on PMTCT, family planning, and GBV services for pregnant women. • Promotion of safer sexual behavior and practices. • Distribution of condoms. • Promotion of HIV testing. • Information on STI symptoms and referrals to health facilities for treatment.

Activity 3: Reinforce and expand access to HIV prevention services for other clients: TB patients, STI clients, and malnourished and bedridden patients. In FY2015, ProVIC continued to enhance the capacity of health care providers to provide high-quality HIV prevention services for clients from multiple entry points by conducting PITC. ProVIC built capacity by providing mentoring and supportive supervision during site visits and quality assurance meetings. In all ProVIC-supported health facilities, emphasis was placed on offering PITC for patients receiving

101

treatment for TB, STIs, or malnutrition, and for patients who are hospitalized for internal medicine or pediatric issues.

The table below provides an overview of individuals tested through PITC at non-PMTCT entry points and their test results. Of the 15,982 individuals tested through PITC at non-PMTCT entry points, 1,615 tested positive (seropositivity of 10.1%). This high seropositivity rate strongly influenced the overall seropositivity rate for ProVIC during this period (4.5%), as the seropositivity rate among pregnant women was only 1.6%.

Table 5. Number of individuals tested at non-PMTCT entry points in Q1 and Q2 FY2015. Haut-Katanga Haut-Lomami Kinshasa Ituri Tshopo Total Total Total Total Total Entry point tested Positive tested Positive tested Positive tested Positive tested Positive 30.3% 33.3% 12% 16.6% 22.2% TB patients 132 6 208 48 9 (40) (2) (25) (8) (2) 9.1% 19.3% 14.8% STI patients 240 1 0% 191 7 0% 27 (22) (37) (4)

102

Haut-Katanga Haut-Lomami Kinshasa Ituri Tshopo Total Total Total Total Total Entry point tested Positive tested Positive tested Positive tested Positive tested Positive 14.8% 11.7% 8.5% 11.5% 7.4% Inpatients 4,788 554 549 397 1,552 (710) (65) (47) (46) (116) Voluntary 8% 8.9% 4.1% 6.7% 7.2% testing and 2,512 246 1,626 1,918 971 (201) (22) (68) (130) (70) counseling

Activity 4: Support health care providers to effectively screen for GBV in the PMTCT setting. A total of 31,269 individuals were screened for SGBV in Q1 and Q2 of FY2015 among pregnant women receiving ANC, their male partners, and other family members in ProVIC-supported facilities.

Activity 5: Provide high-quality support services (medical and psychosocial) to SGBV survivors. In Q1 and Q2, 276 GBV cases were identified and 269 individuals were provided with post-GBV care, which includes a medical consultation and psychological evaluation. The majority of cases screened positive for GBV were in Tshopo (213), identified during individual counseling with pregnant women attending ANC. ProVIC also identified 15 cases of sexual violence. ProVIC’s low achievement in this indicator is due in part to a number of high-volume facilities in Katanga and Bunia that have not yet systematically integrated GBV activities, as well as some difficulties obtaining post-exposure prophylaxis kits for treating cases of rape. ProVIC will provide refresher trainings on GBV screening and care to facilities in Katanga and Bunia and expects results for this indicator to improve in the second half of this fiscal year.

Activity 6: Support community actors by integrating key messages on gender and GBV into PMTCT materials. In the first six months of FY2015, health care workers and ReCos in ProVIC-supported health zones and health facilities integrated messaging on GBV prevention and family planning into PMTCT and HIV prevention services, particularly targeting pregnant women and youth of reproductive age, with emphasis on how to access prevention, care, and support services offered at project-supported facilities. Service providers and volunteers also emphasized the importance of male partner support in increasing women’s ability to adhere to treatment and care regimens, and the contribution of couples HTC in minimizing HIV- related stigma for women and as an entry point to HIV services for serodiscordant couples. In addition, specific messaging on SGBV was delivered during educational sessions on maternal and child health and nutrition activities at antenatal and under-five clinics.

Activity 7: Contribute to efforts of government partners to improve the coordination of interventions and stakeholders in the fight against GBV. ProVIC provided financial and logistical support to the Programme National de Santé de la Reproduction (PNSR) to supervise family planning and GBV services provided by health care workers in ProVIC- supported health facilities in Lubumbashi, Likasi, Sakania, Kapolowe, and Kolwezi (Katanga Province). The PNSR has largely been satisfied with the quality of family planning and GBV services provided by care providers in ProVIC-supported facilities. In FY2015, ProVIC trained and mentored service providers on providing family planning and GBV services, and also ensured that data collection tools, such as registers, GBV screening forms, and family planning consultation forms, were available at project- supported health facilities. Family planning commodities, medicines, and post-exposure prophylaxis were also available at project-supported health facilities. ProVIC will continue to provide training and mentorship to care providers to ensure that any new providers at ProVIC-supported facilities are appropriately trained. In addition, more targeted technical assistance will be provided on correctly completing data collection tools/patient forms and carrying out other services, such as taking patients’ pulse, temperature, and weight.

103

In Q1, ProVIC supported the Ministry of Gender, Family and Children in organizing a workshop in Kinshasa aimed at fostering collaboration and operational synergies between the Agence Nationale de Lutte Contre les Violences Faites a la Femme et a la Jeune, NGOs, and relevant associations/ networks to better combat violence against women and girls. The workshop allowed for the development of a map of NGOs and associations that work in particular focus and intervention areas. A referral and counter-referral system was also set up during the meeting.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Not all health care providers in ProVIC- Provide training and targeted technical assistance supported facilities have been trained in to ensure family planning services are provided providing high-quality family planning services correctly and in accordance with national and national standards for family planning. standards by care providers.

Intermediate Result 2: Improved access to adult and pediatric treatment

Sub-IR 2.1: Maximizing access to ART Activities and achievements Activity 1: Improve the links to ART services for HIV-positive clients at ProVIC-supported sites. During this reporting period, health care providers were coached by the ProVIC team to increase the offering of PITC at all entry points, including MNCH (ANC, labor and delivery, postnatal care, and under-five care) and other entry points (STIs, TB, malnutrition, and in-patient services) at ProVIC- supported sites. ProVIC’s technical team also coached service providers on linking identified HIV- positive patients to care and treatment services and correctly completing referral/counter-referral tools.

A total of 2,456 PLHIV were identified during the reporting period, and 2,332 (95%) newly identified PLHIV were enrolled in HIV care services. Among the 2,332 on care, 1,595 (68%) were eligible for and initiated on lifelong ART. The majority of new PLHIV enrolled in highly active antiretroviral therapy (HAART), 791 (50%), were in Haut-Katanga, followed by 254 (15%) in Kinshasa and 236 (14%) in Ituri.

To strengthen linkages and reduce loss to follow-up, ProVIC focused on providing support to health zone and health facility management teams to improve service integration and utilize task-shifting to address human resource shortages. To improve the quality of services offered and to reduce clinic wait times, service providers were encouraged to provide CD4 counts to HIV-positive individuals on the same day of HIV testing. Job aids and standard operating procedures were also given to health facilities to support observance of national guidelines and standards and to ensure correct completion of national data collection tools, including tracking tools to facilitate patient monitoring.

Activity 2: Complete pre-ART laboratory analysis and biological follow-up for PLHIV in ProVIC- supported sites. CD4 count. PIMA™ CD4 Analyzers located in hub (central) sites, were utilized for testing blood samples from both hub and spoke sites. PLHIV with a CD4 count of less than 500 were placed on ARVs, as were all children younger than 5 years, in accordance with national recommendations. All HIV- positive pregnant women were initiated on HAART regardless of CD4 count.

104

In Q1 and Q2, CD4 counts were provided to 809 PLHIV visiting ProVIC-supported facilities. Figure 6 below provides a breakdown of PLHIV provided with a CD4 count by province and quarter. The low performance in Kongo Central was due to the ending of ProVIC activities in the province and low performance during the closeout period. In Haut-Lomami, low performance was due to the low availability of PIMA™ CD4 Analyzers in the province to conduct CD4 counts—there is only one PIMA™ CD4 Analyzer in Kamina to support the 12 ProVIC facilities in Haut-Lomami.

ProVIC-supported facilities faced challenges documenting CD4 counts at 6 months, as observed during SIMS visits conducted in collaboration with USAID. ProVIC plans to focus on strengthening the provision of CD4 counts in Q3 and Q4 by covering the cost of transporting samples from facilities that do not have PIMA™ CD4 Analyzers to facilities that have this capability.

Figure 6. PLHIV provided with a CD4 count in Q1 and Q2 FY2015, by province and quarter.

300

240 250 208 200

150 108 100 62 69 47 40 50 13 11 9 2 0 0 Haut-Katanga Kinshasa Tshopo Ituri Haut-Lomami Kongo Central Quarter 1 Quarter 2

Viral load. The national PNLS laboratory and four ProVIC-supported health facilities—Kikimi Hospital Center, Bolingani Maternity Center, Binza Maternity Center, and Trinité Kivuvu Hospital Center—began performing viral load testing for all health facilities in Kinshasa in October 2014. However, testing was temporarily suspended in November and December due to malfunctioning laboratory equipment. Further, at the end of February 2015, the PNLS laboratory’s stock of reagents needed for viral load testing expired. As a result of these challenges, the four ProVIC-supported health facilities were able to perform only 48 viral load tests in Q1 and Q2. Of these, 33 had a viral load of less than 40 copies/ml. A new stock of reagents is expected from the Global Fund.

Other biological tests. ProVIC instructs health facility workers to carry out biological monitoring tests (e.g., hemoglobin and liver and kidney function) for all PLHIV prior to initiation on treatment and during follow-up visits. However, results in Q1 and Q2 in this area were poor: laboratories did not have the necessary equipment (e.g., spectrophotometer) to perform tests at most ProVIC sites, including hub sites; clients were unable to pay for testing; and testing was not carried out for PLHIV in accordance with the timeline recommended by the PNLS. Hemoglobin testing tended to be the biological test that was performed the most as it does not require sophisticated equipment. For example, in Haut-Katanga, 137 hemoglobin tests were performed, but only five glycemic tests, four SGOT tests, one creatine test, and no SGPTs or urea tests were performed during the reporting period. Figure 7 provides a breakdown of PLHIV who received a hemoglobin test in Q1 and Q2 by province.

105

Figure 7. PLHIV who received a hemoglobin test in Q1 and Q2 FY2015, by province.

8 29 Haut-Katanga Kinshasa Tshopo 49 137 Ituri Haut-Lomami 9

In Q2, the Supply Chain Management System (SCMS) provided three spectrophotometers to ProVIC to be placed at facilities in Katanga (Kenya General Reference Hospital) and Province Orientale (Mokili Health Center and Ngezi/PNC Health Center). These facilities were chosen because they are high-volume sites and serve as reference centers for other health facilities. A training for eight laboratory technicians and medical biologists from these three facilities was carried out by Labomat Essor (supplier of the spectrophotometers) at the end of Q2 on the proper use of the equipment and preventive maintenance. The facilities will begin using the equipment in Q3, once they receive the necessary reagents and other commodities. In Q2, ProVIC directly paid the national PNLS laboratory to perform testing, which helped to increase the level of biological testing in Kinshasa.

During the E2A extension period, the technical team will strengthen monitoring in this area to ensure that health care providers are following the PNLS-recommended timeline for biological testing, and determine a method to allow samples to be transported to laboratories that have the needed equipment to perform biological analyses. With the additional spectrophotometers in three key hub sites, ProVIC expects results in this area to improve in Q3 and Q4.

Activity 3: Reinforce the retention of PLHIV enrolled in HAART. Improving retention rates has been a key focus for ProVIC in FY2015, with multiple strategies implemented to reinforce retention, including the rollout of the Tier.net patient monitoring tool, strengthening of self-help groups, and enhancement of community-facility linkages through Mentor Mothers and peer educators. During Q1 and Q2, ProVIC’s retention rate was 84%, with 745 of 886 PLHIV still alive and on treatment 12 months following initiation on ART, as shown in the figure below.

106

Figure 8. Percentage of PLHIV known to be on treatment 12 months after initiation on ART.

500 450 446 384 400 (86%) 350 300 250 209 191 200 (91)% 150 115 76 100 (66%) 45 49 59 57 (86%) 50 (76%) 0 Haut-Katanga Kinshasa Tshopo Haut-Lomami Ituri

PLHIV initiated on ART 12 months prior to the start of Q1 FY2015 PLHIV still alive and on treatment 12 months after initiation

As seen in the figure, the retention rate in Tshopo was the lowest (66%) of all the provinces, largely due to the high mobility of the population; women primarily work as traders, so retention poses a particular challenge in Tshopo. Haut-Lomami had the second lowest retention rate (76%); this is due to the distance of Haut-Lomami sites from Lubumbashi, so ProVIC has been unable to implement the Mentor Mother approach and strengthen other community activities focused on adherence and retention counseling.

ProVIC worked to improve patient monitoring primarily through the introduction of the Tier.net application in all ProVIC sites. By collecting individual patient data at each site and aggregating and analyzing Tier.net reports, the ProVIC team was able to perform monthly cohort analyses of patients by site in order to closely monitor the linking of patients to care and treatment services and to identify sites that are having issues maintaining patients in care.

To improve retention, ProVIC strengthened psychosocial support through self-help groups at health facilities, and referrals were provided to Mentor Mother groups for pregnant and breastfeeding women. ProVIC also encouraged peer educators to improve retention by using phone calls, SMS messages, and home visits to reinforce adherence to and retention in treatment regimens in order to reduce loss to follow-up. ProVIC provided an agenda calendar tool to health facilities so service providers were able to better track missed appointments. Messaging was also delivered by ReCos during community education sessions, self-help group meetings, and home visits to promote retention in treatment and care services.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Stockout of pediatric ARVs. • Work closely with ProVIC logistics staff and SCMS to account for and order pediatric ARVs. • Collaborate with the Global Fund to obtain pediatric ARVs. Lack of equipment at facilities for biological • Request clarification from the United States testing. President’s Emergency Plan for AIDS Relief or United States Centers for Disease Control and

107

Prevention on the plan for procuring additional equipment. • Pay national or provincial PNLS laboratories directly to ensure that tests are completed.

Sub-IR 2.2: Maximizing the quality of care and ART services Activities and achievements Activity 1: Provide a high-quality package of care services for PLHIV in ProVIC-supported sites. Through a series of coordinated activities in line with new guidance and targets per the Accelerating Children’s HIV/AIDS Treatment Initiative, ProVIC will continue to promote positive health and dignity to reduce morbidity and mortality among PLHIV. A particular focus will be to continue provision of CTX prophylaxis and treatment in line with United States President’s Emergency Plan for AIDS Relief (PEPFAR) guidance, and to strengthen TB screening and referrals of suspected cases for diagnosis and treatment; STI screening and treatment; nutrition counseling following the nutrition assessment, counseling, and support (NACS) approach; and retention in care through self-help groups.

In Q1 and Q2 of FY2015, a total of 6,626 PLHIV—2,017 males and 4,609 females— out of 6,752 PLHIV currently receiving ART received either a clinical assessment, CD4 count, or viral load count, which represents a 277% achievement against ProVIC’s established six-month target for this indicator. Figure 9 below shows the number and percentage of individuals in ProVIC’s current ART cohort who received one of these services in the first two quarters of FY2015 by province. ProVIC’s high achievement in this indicator can be attributed to additional data received from Kongo Central, the installation of PIMA™ CD4 Analyzers in hub sites to facilitate CD4 counts, and the additional 25 health facilities in Ituri that ProVIC began supporting in Q2 of FY2015.

Figure 9. Number and percentage of PLHIV currently on ART provided with a clinical assessment, CD4 count, or viral load count in Q1 and Q2 FY2015 by province.

4,500 3,967 (115%) 4,000 3,460 3,500 3,000 2,500 2,000 1,406 1,500 822 729 1,000 (58%) (129%) 493 384 231 567 499 395 (125%) 425 (90%) 500 (46%) 0 Haut-Katanga Kinshasa Haut-Lomami Kongo Central Ituri Tshopo

PLHIV currently on ART PLHIV who received at least one clinical assessment, CD4 count, or viral load count.

Out of 2,332 PLHIV who were newly identified HIV positive in Q1 and Q2 of FY2015, 2,237 (96%) received an initial assessment including clinical, CD4, or viral load. In total, 96% of newly identified PLHIV received a clinical care service, with the highest rate in Kinshasa, where all PLHIV received at

108

least one clinical assessment service, and the lowest rate in Kongo Central, where only 33% received a service, primarily due to the low level of activities in Kongo Central health facilities due to the closeout.

Provision of CTX. Provision of CTX is a routine activity that ProVIC continued in Q2 of FY2015. In accordance with PNLS guidance, 100% of PLHIV enrolled in care received CTX prophylaxis to reduce the occurrence of opportunistic infections and diseases. SCMS provides ProVIC-supported health facilities with medications and supplies for CTX, and regular monitoring by health zone management teams ensures appropriate stores of CTX are available at facilities. A challenge encountered in ProVIC- supported facilities was correctly recording data related to CTX prophylaxis in data collection tools. To resolve this challenge, ProVIC provided technical assistance to service providers and worked through scenarios together to ensure that service providers were able to correctly record results related to CTX prophylaxis.

In Q2, following ProVIC’s expansion in Bunia, health care providers from the 25 new ProVIC-supported facilities were trained to provide a complete care package for HIV-positive individuals. During this training, a session was held that specifically focused on the importance of CTX prophylaxis to prevent opportunistic infections. A total of 6,871 PLHIV received CTX prophylaxis in Q1 and Q2; Table 6 below provides the breakdown by age and province. This represents an achievement of 287% against the target set for this indicator.

Table 6. HIV-positive adults and children who received CTX prophylaxis in Q1 and Q2, by province. Kongo Central Katanga Kinshasa Province Orientale Total Under 15 11 387 35 70 503 Over 15 462 4,124 859 923 6,368 Total 473 4,511 894 993 6,871

TB screening, diagnosis, and treatment. TB control remains a major challenge in the DRC. Active and early identification of TB in symptomatic PLHIV is a strategy that can control the spread of TB infection in communities. TB screening for PLHIV has become a routine activity for health care workers in ProVIC-supported health facilities, and 100% of PLHIV who visit facilities are screened for TB. All people who screen as possibly having TB are referred to TB diagnostic and treatment centers (CSDT) for diagnosis, and if needed, TB treatment. To facilitate data collection, TB-specific forms were made available to all project-supported facilities and these forms were completed and placed in patient medical files. In Q2, health care providers in the 25 new project-supported facilities in Bunia were trained on screening and caring for opportunistic infections, including TB and HIV/TB co-infection.

In the first two quarters, 94% of PLHIV (6,231 of 6,618) were screened for TB during their last clinical care service (clinical assessment, CD4 count, or viral load test)—4,326 females and 1,905 males—which represents a 347% achievement against ProVIC’s target for provision of TB screening services. Figure 10 shows the number of PLHIV screened for TB this quarter, by province. ProVIC’s continued high achievement in this area is due to the increasing systematization of TB screening for all PLHIV who visit project-supported facilities for medical consultations and for those newly identified as HIV positive (in prior periods, active TB screening was not carried out systematically for all PLHIV across all project- support facilities). Frequent monitoring visits by ProVIC’s technical team to strengthen systematic screening for TB and training for the 25 new facilities in Bunia also contributed to the continued high achievement in this area.

109

Figure 10. Percentage of PLHIV screened for TB in Q1 and Q2 FY2015, by province.

4,500 3,967 4,000 3,602 (91%) 3,500

3,000

2,500

2,000

1,500 957 (116%) 822 574 1,000 721 461 (116%) 398 493 239 (64%) 384 (104%) 500 231 (103%) 0 Haut-Katanga Kinshasa Kongo Central Ituri Tshopo Haut-Lomami

PLHIV who received a clinical care service (clinical assessment, CD4 count, or viral load test)

Among the 6,231 PLHIV screened for TB, 148 PLHIV were diagnosed as TB positive and initiated on TB treatment. Of these, 52 individuals (35%) with HIV/TB co-infection were receiving treatment for both TB and HIV (27 females and 25 males). The low number of HIV/TB co-infected individuals reported as receiving treatment for both TB and HIV can be partially attributed to poor performance of the referral/counter-referral system, as care providers at ProVIC-supported health facilities were not consistently informed of TB-positive PLHIV who were placed on treatment by CSDTs, which may have caused under-reporting in this indicator. ProVIC’s technical team will carry out monitoring visits during the ProVIC/E2A extension period to work with care providers to improve the reporting of results from CSDTs through the referral/counter-referral system and to ensure that HIV/TB co-infected patients on ART and TB treatment are registered correctly.

Nutrition counseling through health system services. In Q1 and Q2, 3,889 PLHIV (59% of the 6,626 PLHIV who received at least one clinical care service) were nutritionally assessed (using the NACS approach) and identified as clinically malnourished, and 733 (19%) of clinically malnourished PLHIV were provided with therapeutic or supplementary food to improve their nutritional status. Table 7 below shows the number of PLHIV identified as malnourished and those provided with therapeutic or supplementary food by province. In the second half of FY2015, training, technical assistance, and onsite mentorship will be provided to service providers to ensure that all PLHIV in ProVIC’s cohort receive a nutritional screening.

Table 7. Nutrition services provided to PLHIV in Q1 and Q2 FY2015, by province. Haut-Katanga Haut-Lomami Kinshasa Ituri Tshopo PLHIV nutritionally assessed and identified 2,642 99 537 421 190 as malnourished Clinically malnourished PLHIV provided with therapeutic and/or supplementary 360 72 163 129 9 food Percentage of clinically malnourished 13.6% 72.7% 30.4% 30.6% 4.7% PLHIV who received therapeutic food

110

ProVIC is working to systematically integrate the NACS approach at all project-supported health facilities and through community-level interventions. During supervision visits, ProVIC found that the nutritional scorecard was being used by the majority of health care providers to screen all PLHIV across multiple entry points. The scorecard includes the following elements: • Measurements (weight, height, mid-upper arm circumference [MUAC]). • Classification of nutritional status (body mass index [BMI] for adults; MUAC for children and pregnant women). • Nutritional evaluation. • Food insecurity evaluation. • Nutritional counseling (based on nutritional status). • Referrals of malnourished individuals to follow-on care at outpatient and intensive therapeutic nutritional units.

Cooking demonstration sessions and nutritional advice were also provided during self-help group meetings and home visits. The use of BMI to classify nutritional status was an innovation introduced by the Food and Nutrition Technical Assistance III Project (FANTA III), with the approval of the Programme National de Nutrition (PRONANUT). This change allowed service providers to shorten the time for offering nutritional services, as BMI can be quickly calculated once body measurements are taken.

In addition to monitoring nutrition activities in conjunction with PRONANUT and FANTA III, nutritionists in Kinshasa and Katanga Provinces attended a three-day training to serve as nutrition site supervisors to provide assistance to health care providers to deliver better nutrition services following the NACS approach in health facilities. A nutritionist in Binza Health Zone explains Health care providers in the 25 new ProVIC-supported the use of body mass index to classify health facilities in Bunia were also trained on the provision nutritional status to health care workers. of nutritional support following the NACS approach, and a nutritional monitoring form was made available to health care providers to facilitate data collection.

111

Through site visits, ProVIC noted that nutritional services were not always available in all project-supported facilities. In Q3 of FY2015, ProVIC will ensure that health care providers from untrained sites in Kinshasa, Katanga, and Bunia are trained in order to increase the number of sites offering NACS services. The project will also intensify joint supervision visits with PRONANUT to ensure high-quality nutrition services are provided.

Improving retention in care. Self-help groups are the most important element of ProVIC’s broader strategy to provide a wide range of care and support services to PLHIV and to improve adherence to ART. A typical PLHIV self-help group Joint ProVIC/PRONANUT supervision visit is composed of 25 PLHIV, and provides a forum for learning at Kikimi Health Center in December 2014. and sharing, analysis, and decision-making on issues that affect them. Following the end of community-level activities, the majority of existing self-help groups are currently run by Mentor Mothers and include pregnant and breastfeeding women. However, there are some community self-help groups (11 in Kisangani and one in Lubumbashi) previously created by ProVIC that are still functioning, facilitated by ReCos connected to ProVIC-supported facilities. ProVIC plans to continue identifying and revitalizing community self-help groups in Q3.

Immunizations for children of HIV-positive mothers. In Q1 and Q2, ProVIC focused on ensuring that children born to HIV-positive mothers remain compliant with immunization schedules. At follow-up visits, health care providers were reminded to ensure that all children were immunized, in order to minimize the number of children lost to follow-up. During follow-up visits at the health facility level, service providers were reminded to ensure that all children of HIV-positive mothers benefit from services available. All available entry points, such as antenatal clinics and nutritional units, will be used to educate mothers and other family members on the importance of ensuring their children are fully immunized.

STI screening and treatment. All PLHIV are systematically screened for STIs. PLHIV who screen positive are provided with treatment in accordance with the national protocol. In Q1 and Q2, ProVIC provided vials of benzathine penicillin to all project-supported facilities to enable treatment of STIs.

Activity 2: Ensure ART for PLHIV (both adults and children). In the first two quarters of FY2015, ProVIC enrolled 1,595 new PLHIV on ART, an achievement of 124% against the target for this indicator (1,286). ProVIC’s achievement in this area was due to maximization of PITC at non-PMTCT entry points as well as the availability of PIMA™ CD4 Analyzers at ProVIC-supported health facilities, which allowed for a shorter turnaround time for CD4 counts to be provided to PLHIV, and consequently, quicker initiation of eligible PLHIV on ART. The table below shows the number of PLHIV newly enrolled in treatment and the overall number of PLHIV in ProVIC’s ART cohort, by province. At the end of Q2, ProVIC was supporting a cohort of 6,752 PLHIV on ART.

Table 8. PLHIV newly enrolled in treatment and the total number of ProVIC’s ART cohort, by province. Kongo Haut- Haut- Central Katanga Lomami Kinshasa Ituri Tshopo Total Number of adults and children 14 791 113 254 236 187 1,595 newly enrolled on ART

112

Number of adults and children 567 3,460 499 1,406 395 425 6,752 receiving ART

In ProVIC-supported health facilities, service integration was encouraged across the cascade of care, including HTC, care and support, HIV/TB, MNCH, and PMTCT, to improve early initiation on ART for those identified as HIV positive and eligible to receive ART. The ProVIC team also worked with service providers to strengthen linkages with laboratory services to improve diagnosis of HIV and other opportunistic infections (e.g., TB) and biological monitoring.

ProVIC provided technical assistance to facility workers on a number of interventions to facilitate adherence to treatment, such as pillbox organizers, education or counseling by community peer educators and facility workers, couples counseling for serodiscordant couples, follow-ups by phone or SMS, home visits, reminder devices, PLHIV self-help groups, and directly observed therapy.

ProVIC also encouraged health zone teams to decentralize pediatric care and allow trained providers in spoke sites to place and maintain HIV-positive children on ART, thus reducing the time (and distance) patients had to travel to be enrolled on treatment, and improving both access and adherence to ART.

Activity 3: Ensure initial clinical mentoring and follow-up for clients on ART. ProVIC emphasized coaching and mentoring of health care providers on following up with PLHIV on ART. In keeping with the QA/QI approach, the project held monthly meetings with service providers, which included technical, laboratory, and commodity management teams, and health zone management teams to discuss how to improve patient flow, reduce clinic wait times, and monitor PLHIV on ART for patient retention as well as tracking of “ART-ineligible” clients to ensure prompt initiation on ART when patients became eligible. Focus was also placed on ensuring provision of services to reduce morbidity and mortality (e.g., CTX and TB interventions). During these monthly meetings, each health facility would highlight performance deficiencies identified by routine monitoring systems, such as SIMS; the deficiencies were analyzed using quality improvement processes to identify root causes and brainstorm effective solutions.

ProVIC also worked with service providers to strengthen the routine review of children’s medical records to identify and re-engage those lost to follow-up and to analyze the linkage of all HIV-infected adolescents to facility- and community-based care and treatment services. In Q1 and Q2, 855 pregnant adolescents were tested in Kinshasa, of whom six were 14 years old and 846 were between 15 and 19 years old. Of the 855 tested, seven tested HIV positive (1%) and were placed on ART. Mentor Mothers faced challenges convincing adolescents to join Mentor Mother support groups. To address this issue, ProVIC recruited an adolescent pregnant woman to participate in a Mentor Mother training, and she in turn was able to convince other pregnant adolescents to join the support group as well.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Stockouts of HIV test kits so providers were not • Redistribute extra HIV test kits from other able to provide PITC at all entry points. facilities or provinces. Stockouts created a particular challenge for the • Coordinate with PEPFAR/United States Centers 25 new sites in Ituri. for Disease Control and Prevention (CDC) projects to obtain necessary test kits during periods of stockouts, and reimburse the CDC projects for test kits used after SCMS supplies sites with new test kits.

113

Delays in initiating HIV-infected children on • Advocate to the PNLS and health zone pediatric ARVs, as doctors were not available in management teams to define guidelines for spoke sites to authorize initiation on ARVs. task-shifting/task-sharing so nurses are able to place PLHIV on ARVs. • Intensify onsite mentoring of pediatric activities.

Intermediate Result 3: Health systems strengthening supported

Sub-IR 3.1: Capacity of provincial government health systems supported Activities and achievements Activity 1: Strengthen the referral and counter-referral system. Referrals to other health facilities are primarily given for patients to obtain laboratory tests and CD4 counts and for confirmation of diagnosis for suspected cases of TB. ProVIC worked with appropriate governmental health units to improve their capacity to carry out their supervision, coordination, and communication responsibilities in support of the referral system. ProVIC also ensured that referral/counter-referral notebooks were available at all project-supported health facilities to facilitate the functioning of the referral system. ProVIC’s Chief of Party, Trad Hatton, meeting with the Ituri District Commissioner in April 2015. The Tier.net system has allowed ProVIC and supported health facilities to better monitor patients receiving ART services and to follow referrals of PLHIV between health facilities to prevent loss to follow-up. Additionally, activities carried out by Mentor Mothers, peer educators, and ReCos strengthen the link between health facilities and local communities, which facilitates closer monitoring of PLHIV to ensure retention in care and support programs. Community-based self-help groups also contribute to this strengthening of the link between community- and facility-level care and support activities. Additionally, the renewal of support for community-based self-help groups and ReCos has been important in providing community-level counseling to PLHIV on the use of ART and PMTCT services and raising awareness of the importance of adhering to treatment regimens for HIV and other diseases.

Activity 2: Support the government’s supervisory role at all levels. ProVIC provided financial and technical support to the government to improve their supervision of health facilities and individual service providers at the national, provincial, and health zone levels. ProVIC also conducted joint supervision visits to project-supported facilities with the health zone management team to provide assistance and support to health facilities and ensure that health care providers complied with applicable standards and guidelines. These joint site visits allow ProVIC to provide mentorship to the health zone management team on how to monitor HIV activities in their catchment areas; identify challenges faced by facilities in implementing HIV activities and brainstorm solutions; monitor management of commodities and testing supplies; and provide supportive supervision to health care providers. Table 9 details the types of supervision activities carried out in each ProVIC province. Additionally, in April 2015, ProVIC’s Chief of Party, Trad Hatton, visited Ituri to monitor the

114

implementation of project activities in ProVIC’s new sites and to reinforce the project’s relationship with the provincial government.

Table 9. Types of supervision activities by province. Activity Frequency Province(s) Joint supervision visits with the PNLS, PNSR, and ProVIC Quarterly Katanga Data validation reviews by the PNLS Quarterly Kinshasa Quarterly reviews Quarterly Katanga and Orientale Supervision site visits Monthly All provinces (health zone level)

Activity 3: Support functioning mechanisms in health zones. ProVIC continued support to health zones in Q1 and Q2 by providing funding for health zone management teams to carry out technical monitoring, supervision, and coordination functions and to purchase necessary supplies and services, such as Internet and transportation costs, to allow health zones to perform their functions. ProVIC supported 28 health zones in Q1 (including five in Kongo Central) and 24 health zones in Q2 (including four new health zones in Bunia). ProVIC also supported health zone management teams to organize monthly monitoring meetings with all project-supported health facilities and health care providers to monitor the quality of service delivery. During the meetings, general health and HIV data were analyzed and validated, and providers noted constraints and difficulties they faced in implementation, which were discussed and solutions proposed, and shared positive experiences to serve as models or best practices for other providers to improve the quality of services. Issues and questions on the referral and counter-referral process were also discussed. Table 10 outlines the number of providers trained in FY2015, by topic area.

Table 10. Number of providers trained in FY2015, by topic area. Training topic Number of providers trained Laboratory services to improve the quality of PITC; rapid HIV testing; quality assurance; external quality assessment (dried tube specimens, 227 (107 women and 120 men) DBS); biomedical waste management New Option B+ protocol 95 (39 women and 56 men) Tier.net 89 (25 women and 64 men)

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Low availability of PIMA™ CD4 Analyzers, Advocate to the PNLS to recover and refurbish which makes it more difficult to obtain timely unused machines and place the machines in spoke CD4 counts for all PLHIV, particularly at spoke sites. sites, as all of ProVIC’s analyzers are currently kept at hub sites, increasing strain on the referral system and burden on patients to seek follow-up.

Sub-IR 3.2: Strategic information systems at facility levels strengthened Activities and achievements Activity 1: Provide technical monitoring and evaluation assistance to the PNMLS and PNLS at the national and provincial levels. ProVIC monitoring and evaluation (M&E) team members participated in a session of the PNMLS National M&E Task Force to validate the DRC’s submission to the 2014 Global AIDS Response Progress

115

Report. ProVIC staff focused specifically on validating data on PMTCT, ART, and HIV/TB co-infection. ProVIC’s Deputy National M&E Specialist participated in a three-day workshop led by the provincial PNLS in March 2015. During this workshop, PEPFAR and PNLS implementing partners in Katanga focused on harmonizing HIV data/results collected during the last six months of 2014, in preparation for submission of data to the national PNLS for their annual review process. A key recommendation made during this meeting was for PEPFAR implementing partners to provide support to the PNLS to obtain monthly reports from health facilities, particularly in rural health zones with poor accessibility.

Activity 2: Provide ongoing datacard and technical support to local partners to improve M&E reporting. The M&E team supervised health care providers at project-supported facilities on their use of data collection tools. Data clerks were used to support data entry in some health facilities to improve the completeness, accuracy, and timeliness of datacard submissions. The M&E team also carried out trainings in Kinshasa on the use of Tier.net in Q1, and data for treatment indicators are now captured using the Tier.net system. ProVIC planned a data collection training in Q2, which would have included orientation on ProVIC’s new datacard; however, this training will be carried out in Q3, when the updated datacard will be finalized.

Data collection training in Bunia. ProVIC organized a three-day training in March 2015 for staff from the new project-supported facilities in Bunia on ProVIC’s data collection and reporting processes and tools. A total of 15 participants attended the training. Participants were familiarized with general M&E reporting processes, and specifically with ProVIC’s datacard and how to complete it.

Updates to PoVIC’s database. ProVIC’s M&E team received assistance from PATH’s M&E and information technology teams to re-conceptualize and upgrade the ProVIC datacard (to incorporate new indicators), improve ProVIC’s data uploader, and better align ProVIC’s reporting system to PEPFAR Monitoring, Evaluation, and Reporting (MER) indicators.

In Katanga, 34 M&E points of contact and six data clerks were briefed on ProVIC’s new datacard in Q1. In Q2, to facilitate reporting against MER indicators while the datacard was being updated, ProVIC’s M&E team revised the current datacard to include new variables necessary to capture data required for MER reporting. ProVIC briefed those responsible for data entry in ProVIC-supported sites on the interim changes made to the datacard. The project held a separate training with new data clerks to introduce them to ProVIC’s reporting system and the datacard.

Verification of datacards. ProVIC’s M&E team conducted a data quality check of datacards received from all ProVIC-supported health facilities, and ProVIC sent corrections on datacards back to partners as a means of building their capacity for reporting. Each ProVIC health facility submits at least three datacards per month, one each for HTC, PMTCT, and care and support; some facilities may also submit GBV or sensitization datacards.

Activity 3: Reinforce partners’ M&E capacity through regular monitoring, routine data quality assessment, and internal audits. ProVIC’s National M&E Assistant participated in PEPFAR’s Data for Accountability, Transparency, and Impact Monitoring (DATIM) training of trainers in December 2014, and gained Datacard training for M&E staff from new an understanding of the DATIM system, general ProVIC-supported facilities in Bunia.

116

principles of DATIM, and how to deliver DATIM trainings. In all, 20 ProVIC technical and M&E staff (eight national-level staff and 12 provincial-level staff) attended in-country PEPFAR trainings on the DATIM system in April 2015, and ProVIC expects that the DATIM system will be rolled out and operational by the end of Q3.

ProVIC’s M&E team carried out routine site visits at least once at all project-supported health facilities in Katanga and Kinshasa in Q1 and Q2, and at 21 health facilities in Province Orientale in Q2. During the visits, project staff reviewed results achieved by that health facility against their targets, discussed challenges, checked the quality of data collection tools, and provided recommendations and areas for improvement.

ProVIC also carried out 12 data quality audits for health facilities in Katanga and Kinshasa Provinces in Q2, eight in Katanga (facilities in Kapolowe, Manika, and Dilala Health Zones) and four in Kinshasa (Kingasani Hospital Center, Trinité Kivuvu Hospital Center, Kikimi Hospital Center, and St. Hilaire Health Center). The major issues identified during these audits were duplication of data collection tools/records (similar information collected in ANC registries, labor and delivery registries, etc.); incomplete PLHIV patient files; lack of internal data verification and triangulation before transmission to health zone management teams and ProVIC; and outdated registries. To address these issues, the project will provide a training on data collection tools and a separate training on data quality in Q3 under the project’s extension through E2A.

Challenges during the reporting period and proposed solutions Challenges Proposed solutions Bottleneck in uploading data into ProVIC’s ProVIC is adding two additional logins with data M&E database in Salesforce, which delays uploading capabilities on Salesforce, to allow up to completion of the M&E table and quarterly three users to upload data into the M&E database. reporting. Currently, only one individual has the This should ease the bottleneck and enable ProVIC appropriate license/authority to upload data. to more quickly compile quarterly data and complete M&E tables. Inadequate number of provincial M&E staff ProVIC plans to hire three new M&E assistants given the number and distribution of health (one per province) to support rollout and facilities supported by ProVIC and the supervision of new PEPFAR data collection tools geographic size of health zones. and systems, including DATIM. The recruitment process is underway. Delays in partners’ use of new datacards and ProVIC is contracting with Vera Solutions to adapt needed updates to ProVIC’s online M&E the database and datacards to the new reporting database. requirements.

117

SECTION II. PROGRAM MANAGEMENT UPDATE

Administration and finance

ProVIC undertook the following key administrative activities in Q1 and Q2 of FY2015: • Prepared for administrative closeout of the AIDSTAR contract mechanism and transition to the E2A funding mechanism. ProVIC’s closeout plan and proposed inventory disposition plan were submitted to USAID on May 14, 2015. • Ended all fixed obligation grants and accords under AIDSTAR as of March 31, as part of ProVIC’s administrative closeout. • Closed project operations in Kongo Central in December 2014. • Moved the location of the Province Orientale project office to a different location in Kisangani, due to ongoing issues with electricity at the previous location. • Held a refresher training for staff in the Katanga office on compliance with PATH policies and procedures and recommendations from USAID audits. • Conducted a PATH internal audit from November through December 2014.

Human resources. ProVIC continued to experience staff turnover as offices closed, staff left for positions on other projects, or staff left for promotions to high-level positions at other NGOs or donors. Recent departures include Denise Ndagano, former M&E Specialist, who is now working at USAID, and Rianne Gay, former Gender Specialist, who took a position with Pathfinder International.

Environmental monitoring and mitigation activities

Throughout Q1 and Q2 of FY2015, ProVIC continued to provide quality assurance and required materials, equipment, and assistance to support comprehensive biomedical waste management in all supported sites. ProVIC and its partners conducted periodic checks of the project’s adherence to the Environmental Mitigation and Monitoring Plan (EMMP) during integrated supervision visits to each site. During these visits, project staff used a checklist to monitor and verify the quality of all activities. This checklist includes a specific section for tracking environmental mitigation and monitoring activities in line with USAID’s health care waste management guidelines and national norms. Through supervision visits, ProVIC has ensured that service providers in supported sites follow the EMMP and respect mutually agreed-upon divisions of roles and responsibilities. ProVIC staff conduct regular supervision visits to each site.

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

In Kinshasa, Katanga, Bas-Congo (for the final time), and Province Orientale, ProVIC continued to supply biomedical waste management supplies to ensure proper handling, sorting, collection,

118

transportation, and disposal of biomedical waste. All sites received a biomedical waste management kit containing a minimum supply of the following consumable and reusable waste management materials:

Single-use needles and tubes Rubber boots Brooms and brushes Latex gloves Rubbing alcohol Mops Trash cans Bleach Shovels Sharps disposal containers Trash bags Detergents Rubber gloves Dustpans Wheelbarrows Rubber aprons Hoes Masks

During the supervision visits, ProVIC staff assessed that there was an overall improvement in the management of biomedical waste across the production, incineration, and disposal stages, as well as in the availability of supplies. ProVIC will continue to promote the importance of biomedical waste management by involving site managers in establishing committees for biomedical waste management in Q3.

119

References

i United Nations Development Programme (UNDP). 2014 Human Development Report: Sustaining Human Progress: Reducing Vulnerabilities and Building Resilience. New York: UNDP; 2014. ii US President’s Emergency Plan for AIDS Relief (PEPFAR). Democratic Republic of the Congo Operational Plan Report FY 2012. Washington, DC: PEPFAR; 2013. iii Ministère du Plan et Suivi de la Mise en œuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé Publique (MSP), ICF International. Democratic Republic of Congo Demographic and Health Survey 2013-14: Key Findings. Rockville, MD: MPSMRM, MSP, and ICF International; 2014. iv Saul K. ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo. Case Study Series. Arlington, VA: John Snow, Inc./AIDSTAR-One; 2012. v ProVIC data from FY2010–FY2014. vi Mulongo S, Kapila G, Bondole J, Hatton T, Burke B, Mbwolie H. Re-envisioning the champion communities approach to better serve urban populations in the Democratic Republic of the Congo [poster presentation]. Presented at: 20th International AIDS Conference, 2014; Melbourne, Australia. vii Makwelebi V, Kapila G, Ntumba G, Mbwolie H, Hatton T, Ndagano D. Mobile “moonlight” voluntary HIV counseling and testing for men who have sex with men in Kinshasa, Democratic Republic of Congo [poster presentation]. Presented at: 19th International AIDS Conference, 2012; Washington, DC.

120