QUARTERLY PROGRESS REPORT
USAID SAFE: Supporting an AIDS-Free Era Program Annual Report
(inclusive of 4th Quarter – July 1 to September 30, 2019)
Submission Date: November 8, 2019
Contract Number: AID-611-C-17-00001 Activity Start Date and End Date: 2017 August 08 to 2022 August 07 COR Activity Manager: Michelle Kim
Submitted by: U S A I D / S A F E John Snow, Inc.
This document was produced for review by the United States Agency for International Development Zambia (USAID/Zambia). 2
PROGRAM OVERVIEW/SUMMARY
USAID SAFE: Supporting an AIDS-free Era Program (USAID Program Name: SAFE)
Activity Start Date and End August 08 2017 to August 07 2022 Date:
Name of Prime Implementing John Snow Inc. (JSI) Partner:
[Contract/Agreement] AID-611-C-17-00001 Number: Name of Abt Associates Inc., Catholic Mission Medical Board, and Subcontractors/Subawardees: mothers2mothers
Geographic Coverage (cities Zambia: Central, Copperbelt, and North Western Provinces and or countries)
Reporting Period: Quarter Four, FY 2019: July - September 2019
Funding source/spigot: (if PEPFAR/Global Health (includes program areas: HIV/AIDS, multiple sources, give percentage of each) Maternal and Child Health)
Does this activity have a Yes costed work plan?
Pipeline months: July-September 2019
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Acronyms
ANC antenatal care ART antiretroviral therapy ARV antiretroviral CBV community-based volunteer CHV community health volunteer DAR Daily Activity Register DSA daily subsistence allowance DSD differentiated service delivery EAC enhanced adherence counseling ECD early childhood development EID early infant diagnosis FP family planning FY financial year G2G government-to-government GRZ Government of the Republic of Zambia HCW health care worker HIV human immunodeficiency virus HIVST HIV self-test HTS HIV testing services JSI John Snow, Inc. LARC long-acting reversible contraceptives LTFU loss to follow-up m2m mothers2mothers M&E monitoring and evaluation MMD multi-month dispensing MOF Ministry of Finance MOH Ministry of Health MS Medical Superintendent MSL Medical Stores Limited MTCT mother-to-child-transmission NAC National AIDS Council NACS nutritional assessment, counseling, and support OPD outpatient department PC professional counselor PCR polymerase chain reaction PEPFAR President’s Emergency Plan for AIDS Relief PHO Provincial Health Office PITC provider-initiated testing and counseling PLHIV people living with HIV PMP performance monitoring plan PMTCT prevention of mother-to-child transmission PNS partner notification services PrEP pre-exposure prophylaxis PY Program year 4
QA quality assurance QI quality improvement SIA strategic information assistant SIMS Site Improvement through Monitoring Systems TB tuberculosis TSS technical supportive supervision TPT tuberculosis prevention therapy TWG technical working group USAID United States Agency for International Development VL viral load VMMC voluntary medical male circumcision
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Table of Contents
Program Overview Acronyms ...... 3 Table of Contents ...... 5 I. Scope/Introduction...... 7 II. Summary of Results to Date ...... 8 III. Progress Narrative ...... 9 IV. Implementation Status ...... 11 Objective 1: 95 Percent of HIV-Positive Individuals Know their HIV Status ...... 11 Objective 2: Initiate 95 Percent of HIV-Positive Individuals on ART ...... 18 Objective 3: Ensure that 95 Percent of Those on ART are Virally Suppressed ...... 31 Objective 4: Strengthen the Health System to Support the Objectives of 95/95/95 ...... 34 Objective 5: Provide Voluntary Medical Male Circumcisions to Priority Populations to Avert New Infections ...... 36 Objective 6: Integrate Family Planning Services into 95 Percent of HIV Service Delivery Locations ...... 39 Objective 7: Reach 90 Percent of Eligible HIV-positive Adults and Children with NACS 42 Management of Medical Waste ...... 46 In the period under review, SAFE supported facilities to manage different types of medical waste. SAFE has an Environmental Mitigation and Management Plan (EMMP) which provides a general framework which must be adhered to in the process of managing medical waste (see table 5)...... 46 Objective 8: Strengthen M&E Capacity at the Facility, District, and Provincial Levels for Improved Program Management ...... 48 Objective 9: Strengthen the Public Financial Management Systems of the Ministry of Health and Ministry of Finance to Enable Efficient Use of Direct G2G Funds from USAID ...... 50 V. Management and Administrative Issues ...... 56 Administration ...... 56 Human Resources ...... 56 Procurement ...... 57 ANNEX A: Progress Summary ...... 59
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I. Scope/Introduction
The U.S. Agency for International Development (USAID) SAFE (Supporting an AIDS-Free Era) program works to reduce HIV mortality, morbidity, and transmission, while improving nutrition outcomes, cervical cancer screening, and family planning integration. The five-year (2017–2022) program operates in three provinces: Central (starting 1st October, 2017), Copperbelt (starting April 2, 2018), and North-Western (starting 2nd April, 2018) and is implemented by John Snow, Inc. (JSI) in partnership with Abt Associates, Inc., mothers2mothers (m2m), and the Catholic Medical Mission Board.
USAID SAFE works with the Government of the Republic of Zambia (GRZ), private-sector actors, and civil society institutions at the national, provincial, district, facility, and community levels to increase access to antiretroviral therapy (ART) for HIV-positive adults and children; reduce the incidence of new infections; improve nutritional assessment, counseling, and support (NACS) and family planning services; and increase the capacity of local health institutions to serve HIV-affected populations.
USAID SAFE comprises three major technical components: 1. Direct service delivery and technical assistance for HIV services 2. Strengthening of monitoring and evaluation (M&E) systems for improved Program management 3. Public financial management capacity building of the Ministry of Health (MOH) and Ministry of Finance (MOF) in support of government-to-government (G2G) activities.
The USAID SAFE program is organized around nine clearly defined and interconnected objectives, each of which must be fully completed to contribute to the Program’s overall success: 1. Ensure that 95 percent of HIV-positive individuals know their HIV status. 2. Initiate 95 percent of those who tested positive on ART. 3. Ensure that 95 percent of those on ART are virally suppressed. 4. Strengthen the health system to support the 95/95/95 objectives. 5. Provide voluntary medical male circumcision (VMMC) to priority populations to avert new infections. 6. Integrate voluntary family planning (FP) services into 95 percent of HIV service delivery locations. 7. Reach 90 percent of eligible HIV-positive adults and children with NACS. 8. Strengthen M&E capacity at the facility, district, and provincial levels for improved Program management. 9. Strengthen the public financial management systems of the MOH and MOF to enable efficient use of direct G2G funds from USAID.
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II. Summary of Results to Date
The table below shows results for annual progress report (APR) of program year (PY) 2 in 244 public facilities, 28 private facilities with 87 Labs offering technical support. For each indicator, achievements by the end of the reporting period were compared with the annual target to determine whether that indicator is on target or not. USAID SAFE is applying specific achievement strategies for each indicator to meet the target by the end of the next quarter.
Table 1. USAID SAFE Results as of Quarter 4, FY* 2019 Annual Q1 Q2 Q3 Q4 Cumulative % Achieved towards Standard Indicators Target FY19 FY19 FY19 FY19 Achieved annual target
HTS_TST: Number of people tested for HIV 540,975 321,881 313,334 241,469 152,386 1,029,070 190%
HTS_TST_POS: Individuals who were tested 34,518 20,410 19,081 16,405 12,750 68,646 199% and received their positive results Positivity Yield 10% 6.3% 6.1% 6.8% 8.4% 6.7% 6.7% PMTCT_STAT: Pregnant women who know 95% 98% 97% 97% 96% 97% 97% their HIV status LINKAGE: 95% of those who test positive are 95% 93% 93% 99% 105% 97% 97% put on treatment TX_NEW: Number of newly-diagnosed adults 59,902 18,997 17,741 16,261 13,325 66,324 111% are commenced on ART TX_CURR: Adults and children currently 311,791 220,745 234,883 248,751 270,103 271,580 87% receiving antiretroviral therapy PMTCT_ART: Pregnant women on ART to 95% 89% 94% 92% 93% 92% 92% reduce MTCT during pregnancy TX_PVLS, N: Number of ART clients with VL 90% 30,166 110,549 122,377 167,940 167,940 90% result <1000 TX_PVLS, D: Number of ART clients with a VL 310,969 37,787 127,686 143,607 186,420 186,420 60% result in their medical record VMMC: Number of males circumcised 61,190 27,359 13,517 16,942 26,460 84,278 138% CUSTOM: Number of clinics with integrated 284 202 202 209 209 209 74% NACS services *FY: fiscal year 9
III. Progress Narrative
Number of people tested and received results (HTS_TST) and number of people who tested positive (HTS_TST_POS): During FY19 Q4, HTS were provided to 152,372 individuals of which 12,751 (8.4%) were newly diagnosed as HIV positive. This represents a quarterly achievement of 113% with regards to the provision of HTS and 148% towards HIV case finding (positives). For more information, see Sub-objective 1.1
Number of pregnant women who know their HIV status (PMTCT_STAT): During FY19 Q4, 29,352 new pregnant women attended antenatal services. Ninety-five percent (28,028) had a documented HIV status; 92% (25,759) were newly tested while 8% (2,269) were previously known to be HIV positive. For more information, see Sub-objective 1.2.
Number of HIV-exposed infants know their HIV status (PMTCT_EID/HEI_POS): During Q4, 6,373 infants received a virologic test. This represents 196% EID coverage of the expected deliveries (6,373/3,245). It further includes all babies who tested this reporting quarter even though they were born in the previous quarter. For more information, see Sub- objective 1.3.
New clients initiated on ART (TX_NEW): For FY19 Q4, 13,325 HIV positive clients were initiated on ART which represents 89% of the quarterly target. This represents an 18% drop from the 16,302 reported in the previous quarter but demonstrated high linkage with 105% of those identified to be HIV positive found through HIV testing. For more information, see Sub- objective 2.1.
Number of people currently on ART (TX_CURR): At the end of FY19 Q4, the number of clients that were active on ART (TX_CURR) was 270,103. This shows a net new of 21,352 from 248,751 that was reporting in Q3. For more information, see Sub-objective 2.3.
Number of males circumcised through voluntary medical male circumcision (VMMC_CIRC): During FY19 Q4, 26,460 clients were circumcised through surgical technique contributing to the achievement of 173% of the quarterly target of 15,297. For more information, see Objective 5.
Number of facilities with integrated FP services (FPINT_SITE): Hundred percent (100%) of all supported facilities had integrated family planning services during Q4 with a total of 1,072 service delivery points that had integrated family planning service. The service delivery points include ANC/MCH, Care & Treatment and HIV testing points. For more information, see Objective 6.
Number of facilities with NACS: In Q4 127,370 PLHIV were assessed for nutrition using an anthropometry assessment in 209 facilities that have integrated NACS in HIV services. A majority of clients assessed for nutrition were adults above 30 years, 73% (93,088), followed by those aged 15-24 years, 21% (26,934), and lastly children below 15 years at 6% (7,348). For more information, see Objective 7.
Health system strengthening: In Q4, USAID SAFE supported the MOH to implement 10 multi-month dispensations by facilitating the movement of ARVs from regional medical stores hubs and district health offices to Service Delivery Points, thereby improving stock availability. For more information, see Objective 4.
Strengthening M&E capacity: USAID SAFE continued to effectively collect routine service delivery data from all the supported facilities across all the three SAFE supported provinces. During this reporting period, 412 SIAs and facility in-charges were trained in SmartCare. For more information, see Objective 8.
Strengthening the public financial management systems of MOH and MOF: In the quarter under review, public financial management systems strengthening activities in Lusaka, Central, and Copperbelt provinces focused on continued implementation of and adherence to the Risk Mitigation Plans as tools for strengthening public financial management and human resource management systems. For more information, see Objective 9.
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IV. Implementation Status
Objective 1: 95 Percent of HIV-Positive Individuals Know their HIV Status Sub-objective 1.1: 143,699 individuals have received HIV testing services and received their results
Key Achievements HTS annual target: 540,975 Quarter 4 achievement: 152,372 Cumulative achievement on HTS: 1,029,019 (190%) Positives annual target: 34,518 Quarter 4 achievement: 12,751 Cumulative achievement on Positives: 68,647 (199%) Positivity yield annual target: 10% Quarter 4 achievement: 8.4%
During FY19 Q4, HTS were provided to 152,372 individuals of which 12,751 (8.4%) were newly diagnosed as HIV positive. This represents a quarterly achievement of 113% with regards to the provision of HTS and 148% towards HIV case finding (positives). Although the Q4 positives represent a 22% drop from the 16,405 identified in Q3, there was an improved yield from 6.8% to 8.4%, indicating better targeting and increased contribution by HIV index and Partner Notification Services (PNS). This quarter saw index contribution to total positives increase from 32% in the previous quarter to 37%. Additionally, continuous improvements and innovations in programming, including increased supportive supervision, mentorship, capacity building, and integration of the HIV screening tool continue to contribute towards improved HIV positivity yield. For example, the introduction of the HIV screening tool has led to smart testing: only those with a high likelihood of testing positive are being tested.
By province, 61,790 clients received HTS in Central and 4,928 were identified as HIV positive representing a yield of 8%. Copperbelt had the same yield of 8% (6,507/81,190) and North- western recorded a 14% (1,317/9,392) yield. North-western has fully integrated the HIV screening tool with buy-in from the MoH and facility staff, likely contributing to the higher yield. HIV yield was proportionally high with VCT modality (14%) compared to other provinces at 7% and 10% for Central and Copperbelt, respectively. Additionally, index testing contributed 48% of all positives during this reporting period for North-western. In order to improve yield, the team will continue to integrate the HIV screening tool into provider delivered HTS and divert resources to index testing and PNS.
USAID SAFE continued to offer HTS through index, VCT, emergency ward, ANC, inpatient, VMMC, and Under5 and Other PITC modalities. Of all who were identified as HIV positive, case finding was the most successful in VCT and index testing: 5,349 were identified through VCT (9% yield, 42% of all positives), and 4,777 through index testing (26% yield, 37% of all positives). PITC contributed 2,625 positives (4% yield, 21% of all positives). 12
The program continued to use data to inform programmatic changes; for example, data analysis showed a higher testing gap among males. With this evidence, the program targeted females identified to be living with HIV (newly diagnosed and those already on ART) and approached their sexual partners for targeted testing. Males tested through the index model contributed 44% towards total positives for this model compared to 38% in other modalities combined. This shift towards increased targeted testing among males is in line with PEPFAR’s recommendation and ZamPHIA. The yield was higher among females at 9.2% than among males at 7.4%. This is in line with ZamPHIA results which indicated that females have higher HIV prevalence compared to males. Cumulatively in FY19, SAFE supported HTS for 1,029,033 representing 190% achievement of the annual target of 540,975, and identified 68,648 PLHIV, representing 199% achievement of the annual target of 34,518. The testing volumes were high because the MoH had a universal testing policy that really drove testing in public facilities. However, with donor advocacy in Q2, the government embraced high impact testing strategies which helped the dramatic decrease in testing volumes. The observed trend in positivity yield deserves a comment. As soon as the screening tool was introduced there was an observed reduction in the absolute numbers of people who tested positive for HIV. However, there was an increase in the positivity yield. SAFE identified 20,410 PLHIV in Q1, 19,081 in Q2, 16,405 in Q3, and 12,751 in Q4. There are several permutations advanced for this phenomenon. Firstly, it is that the screening tool does rule out all unnecessary tests leaving only those people with a high suspicion of index for HIV positivity to actually undergo the test. Secondly there is that school of thought which is speculating that we could actually be approaching epidemic control and those people who could be positive and have never tested are becoming more and more scarce. However, the program will continue with targeted strategies such as index testing to ensure those at highest risk are reached with testing services and find a friendly environment (private) to feel comfortable answering screening questions.
Linkage into Treatment
In this reporting quarter, 105% of all HIV positive clients identified were linked to HIV Care and Treatment Services (proxy measure of linkage). The linkage rate includes newly identified positives, clients transferred from community testing partners for ART initiation in the facility, and clients who were identified in the previous quarter and were initiated in this reporting period. This quarter saw an increase in linkage rate from 99% in Q3 to 105%. The program staff continued to physically escort clients identified during index testing to ART initiation points and strengthened the Test and Treat strategy with other PITC model within the facilities.
Index Testing
The program continued to track the index cascade to identify bottlenecks and provide immediate remedial action to overcome challenges. During FY19 Q4, 17,318 index clients were offered and accepted index testing by eliciting contacts. Index clients included newly identified HIV positive clients, those already enrolled on ART clients, and those with high viral load (unsuppressed clients). Those who accepted index testing provided 25,312 contacts, of whom 13
17,988 were sexual contacts and 7,314 were biological children below 15 years (see Figure 1). Nineteen percent (4,717/25,312) of elicited contacts were known to be HIV positive already. From all eligible sexual contacts elicited, 93% (12,541/13,420) received testing services. A total of 876 (7%) sexual contacts not tested gave appointments for the next quarter, while others were not available during home visits or provided incorrect directions, some households were not located, and some people were not ready to test. Testing rate among children was 79% and we believe there is still room to help improve screening services for children.
The overall yield of index testing was 26%; 36% among sexual contacts (4,455/12,544) and 6% among biological children under 15 (322/5,653). The index contribution to the total positives identified through HIV testing was 37%, an improvement from 32% last quarter. The increased contribution of positives from index testing is further attributed to the formation of dedicated teams (CBVs, Index Champions, and PCs) in each supported facility that focused on index testing by targeting all positives identified through all program testing modalities. The program further recruited an additional 34 professional counsellors (PCs) on August-September 2019 to enhance targeted testing. The PCs were deployed in selected high-volume sites.
Figure 1. HIV Testing Cascade of Contacts of Index Clients, FY19 Q4 (USAID SAFE 2019)
The program will continue to scale-up index and PNS through on-going mentorship, TSS and onsite mentorship; increased index teams’ formation; and redirection of HTS resources to index and enhanced monitoring and evaluation. The overall linkage rate of 98% (4,681/4,777) was achieved with index testing and only counted newly identified positive clients for Q4.
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JSI Washington Senior HTS Technical Advisor, in Copperbelt province providing on-site mentorship to CBVs, PCs and GRZ counsellors on how to analyze index testing such as who is elicited and how many are sexual contacts.
Challenges Index registers are not fully completed. In order to address this issue, clinical supervisors, HTS coordinators, and professional counselors are providing mentorship to CBVs and strategic information officers on data collection, entry, storage, and retrieval. Low levels of awareness regarding index testing in most facilities. In order to address this gap, SAFE leveraged G2G funding from the PHOs in Copperbelt and Central provinces to train facility in charges and ART in charges and health workers in index testing. Stigma in SAFE-supported facilities is being addressed through interactive community radio programmes. Next steps During the first quarter of FY20, USAID SAFE will intensify Technical Supportive Supervision (TSS) and onsite mentorship to trained index testing Champions and MoH and USAID SAFE supported staff on index testing, documentation, and use of the HIV testing screening tool. USAID SAFE will engage more community-based strategic gate keepers such as headmen/male traditional leaders, religious leaders, and other partners working with adolescents/youths to reach the hard-to-reach groups with HIV testing including index testing. USAID SAFE will intensify the involvement of MoH staff at provincial, district, and health facility levels through joint data review meetings, onsite mentorship, and training/orientation on targeted HIV testing (i.e. index testing, HIVST and use of HIV Testing Screening tool) to make sustainable the work SAFE is currently supporting in all three provinces.
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HIV Self-Testing During FY19 Q4, 14,609 HIVST kits were distributed through 129 health facilities in the three supported provinces. The majority of HIVST kits were distributed through the directly assisted model (77%, 11,191) with 23% (3,418) distributed through the unassisted model. This is mainly because HIVST is used as a triage strategy at outpatient department (OPD) to screen out clients during busy times as the best practice in the implementation of HIVST. The unassisted distribution is mainly for secondary users who are often partners of antenatal care (ANC) attendees and sexual partners of those visiting the health facility.
The highest distribution (51%) was in Copperbelt, followed by North-western at 28% and Central at 21%. HIVST is distributed during mobile outreach activities where facilities target men for testing. Forty-four percent (6,498) of the kits were distributed males and 56% (8,111) to females. Targeted distribution of HIVST kits is at 65% (9,575/14,609) for males and females aged 25 years and above, the age group with a high HIV prevalence according to ZamPHIA. Additionally, among those under 25 years, HIVST kits distribution reached 63% (3,165/5,034) of adolescent girls and young women (AGYW), compared to 37% among adolescent boys and young men (ABYM) aged 10 to 24 years.
In FY19, SAFE supported HIV testing of 44,863 people with HIVST, achieving 46% of the annual target of 96,936. The low achievement was mainly due to a now phased-out plan of rolling out HIVST by the MoH. HIVST distribution was initially introduced in Ndola and Kitwe districts in Copperbelt province in April 2019. Additionally, there is still resistance by health providers to distribute kits especially for unassisted model as there is a lower chance of result return. Documentation of HIVST results by those conducting screenings at facilities is still a challenge as there is no MOH register to capture this information. However, through the HTS Technical Working Group (TWG), a new HIVST distribution register has been developed to use when HIVST kits are distributed in facilities. However, it does not provide the space to capture results from HIVST screening. The program will improvise to document screening results in the comments section and further document HIVST as an entry point in the HTS. This practice will be achieved through TSS, constant onsite mentorship, and the planned training of CBVs and other health workers in FY20. Challenges There are still some MoH staff that do not fully support targeted testing through use of HIVST. Facility staff have not yet grasped the distribution models of HIVST, which poses challenges with the implementation of HIVST.
Next steps USAID SAFE will continue to engage the MoH at various levels to help them understand the reasons for targeted testing and the need to further reduce unnecessary testing through use of the screening tool. USAID SAFE will continue providing the necessary support, re-orientation, and mentorship for facility-based staff to fully understand the concept of HIVST and to improve the distribution models available at facility level.
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Sub-objective 1.2: 111,911 pregnant women attending ANC know their HIV status Key Achievements PMTCT_STAT annual target: 111,911 Quarter 4 achievement: 28,028 Cumulative achievement: 118,998 (106%)
During FY19 Q4, 29,352 new pregnant women attended antenatal services. Ninety-five percent (28,028) had a documented HIV status; 92% (25,759) were newly tested while 8% (2,269) were previously known to be HIV positive. Among those newly tested for HIV, 968 were identified to be HIV positive, representing a yield of 4%. Including known positives, there were a total of 3,237 HIV positive pregnant women.
The program has continued to advocate and sensitize the public on the importance of male involvement in PMTCT services and during the reporting period, 6,761 pregnant women attended ANC with their partner. Of the men who attended with their partner, 83% tested for HIV. 203 couples had discordant results and negative partners were enrolled on PrEP.
Cumulatively in FY19, USAID SAFE provided support to ensure that 118,998 pregnant women had a documented HIV status, reaching 106% of the annual target of 111,911.
Figure 2. PMTCT_STAT: Known HIV Status of Pregnant Women, by Quarter (USAID SAFE 2019)
Adolescent Girls and Young Women (AGYWs) Activities The aim of the USAID SAFE Teen Moms intervention is to collect the data from 34 USAID SAFE supported Mothers-to-Mothers (M2M) sites and verify teen mom enrollment into mentor mother program and linking them to key interventions with other USAID/PEPFAR implementing partners working within USAID SAFE sites. During this reporting period, mentor mother conducted 1,874 home visits to HIV-positive women with a focus on retention in care 17
for newly diagnosed and known-positive that have on ART for a while. Table 1 shows number of AGYW enrolled in M2M program in 34 supported facilities.
Table 1: Enrollment and testing uptake among AGYW from Mentor mothers supported sites, Jan-Aug 2019 (USAID SAFE, 2019)
Enrollment and testing cascade amongst AGYW AN+PN clients, Jan – 10 -19yrs 20 – 24yrs August 2019
Number currently enrolled at the facility 6064 10710
Number with known HIV status 204 753
Number tested within the month and received results 5860 9957
Number of new identified HIV+ adolescents within the month 76 264
Number of HIV negative adolescent mothers retested within the month 1957
The mentor mothers supported adolescent teen mom activities in the period under review including the following: Enrolled HIV positive teen toms into the M2M program Ensured access of high impact services for teen moms Conducted home visits Provided services via mentor mothers, including psychosocial counselling, adherence counselling HIV testing, DBS collection, health talks, linking of HIV positive mothers to other services within the facility (e.g. clinical care, family planning) Referred HIV negative teen moms to high impact services
Mentor mothers in the community are supporting AGYWs through: Conducting home visits to provide continued psychosocial support Providing services to household members, including HIV index testing for male partners, nutritional assessment and counselling (NAC), growth monitoring and promotion (under five), adherence assessment. Enhancing retention in care by conducting loss to follow up
Sub-objective 1.3: 14,847 infants born to HIV-positive mothers get virologic HIV test done within 12 months of birth
Key Achievements PMTCT_EID annual target: 14,847 Quarter 4 achievement: 6,373 Cumulative achievement: 18,639 (126%) 18
During Q4, 6,373 infants received a virologic test. This represents 196% EID coverage of the expected deliveries (6,373/3,245). It further includes all babies who tested this reporting quarter even though they were born in the previous quarter. The majority (55%, 3,475) of the infants tested were less than two months old at the time of sample collection and 53 (1.5%) were found positive. Of those tested between two and 12 months of age, 81(2.7%) were found positive. The positivity overall was 2.1% (134).
USAID SAFE has seen a steady increase in the total number of tests conducted for HEI in the past quarter as compared to the last three reporting periods in FY19. The increase in HEI was mainly attributed to a huge scale up exercise in all high volumes to ensure greater coverage of EID and the mentor mothers who were trained in EID testing, which greatly improved the testing rates at all the timelines of the EID cascade. In addition, USAID SAFE conducted intensified supervision and mentorship on EID testing and ensured follow up on all infants that were not tested, as well as improved the TAT for EID results to the facilities and on file. Sample collection was prioritized at facility level and testing at LAB level. There was further an effective courier system and training of mentor mothers in HIV testing and DBS blood sample collection. E-labs have also started transiting results back to the facilities, this will be scaled up in the coming quarters. No target for this indicator has been set by USAID. SAFE will continue ensuring that all exposed infants have their virologic test done before the age of 12 months.
USAID SAFE observed an increase of over 10% in total tests done and results received this quarter as a result of multiple interventions. The team supported health facilities to focus on the mother-baby pair, ensuring that each mother is reminded to bring the baby for early infant diagnostic testing. The team continued strengthening the EID/VL courier system and e-labs to ensure that the collected samples are delivered to the testing lab in the shortest period of time and results are electronically transmitted back to the facility.
To ensure integration and sustainability of the Mentor Mother model and activities, the regional teams organized 219 SAFE supported facilities from 19 districts to attended a one-day orientation meeting on the new PMTCT guidelines and DBS collection. DBS testing at birth and nine months for exposed infants was not being conducted. This has since been rolled out to all facilities and testing is being conducted to enhance EID through mentor mothers. Objective 2: Initiate 95 Percent of HIV-Positive Individuals on ART Sub-objective 2.1: ART initiation, and Sub-objective 2.2: 59,902 newly diagnosed adults and children are enrolled into antiretroviral therapy (ART)
Key achievements TX_NEW annual target: 59,902 Quarter 4 achievement: 13,117 Cumulative achievement: 66,176 (110%) Linkage rate target: 95% Linkage rate achievement for Q4: 103% 19
Cumulative linkage rate: 97%
For FY19 Q4, 13,117 HIV positive clients were initiated on ART which represents 89% of the quarterly target. This represents an 19% drop from the 16,261 reported in the previous quarter but demonstrated high linkage with 103% of those identified to be HIV positive found through HIV testing. The drop is mainly due to decreased number of new positives identified in the same reporting quarter. However, the program will continue with targeted strategies such as index testing to ensure those at highest risk are reached with testing services and find a friendly environment (private) to feel comfortable answering screening questions in order to initiate more clients on ART. The linkage rate in this case includes newly identified positives, clients transferred from community testing partners for ART initiation in the facility, and some clients who were identified in the previous quarter and initiated in this reporting period. This quarter saw an increase in linkage rate from 99% in Q3 to 103%. This was due to intensified involvement by CBVs, index champions, and PCs in ensuring that all clients identified to be HIV positive during index testing and mobile outreach activities are physically escorted to the health facilities for immediate initiation. The program further intensified same day ART initiation with other PITC modalities.
Central province had the highest linkage rate at 106% (5,217/4,928), followed by Copperbelt at 103% (6,704/6,507) and North-western at 95% (1,256/1,317).
The program’s methodology in counting newly initiated clients on ART excludes clients who are transferred in from other facilities and those re-starting ART due to previous interruption. This has been emphasized to the Strategic Information Assistants (SIAs) as something to pay close attention to during data collection. Additionally, Senior SIAs and SI Officers have been doing random checks with health facilities to ensure consistency in data collection. Cumulatively, in FY19, USAID SAFE supported the initiation of 66,176 on ART, an achievement of 110% of the annual target of 59,902. Figure 3. TX_NEW: new initiations on ART, by Quarter (USAID SAFE 2019)
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Pre-exposure prophylaxis
During the second half of FY19 (April-Sept 2019), 5,322 individuals were newly initiated on PrEP. This semi-annual indicator marks a 188% increase from 1,850 that was achieved during the first six months of the program year (October 2018 to March 2019). This has been due to intensified demand creation and awareness through MoH support during facility morning health talks on the availability of PrEP services and their importance. USAID SAFE also trained clinicians on PrEP and conducted facility-based orientations for HCWs and CBVs which increased the confidence of the clinicians to initiate and enroll clients on PrEP. The CBVs also gained the counseling skills required to encourage clients in discordant relationships to be on PrEP. Through collaboration with partners working with key populations, SAFE also reached out to these clients to access PrEP.
Of all new PrEP initiates, 53% (2,796) were females compared to 47% (2,526) males. Among new PrEP users aged 15-24 years, 66% (519/781) were AGYW compared to their male counterparts at 34% (262/781). Females further constituted a higher proportion at 54% in the age band of 25-39 years. Males led by 57% in the ages 40 years and above compared to 43% of females. Results show that AGYW are accessing PrEP services, illustrating the need to continue strengthening collaboration with DREAMS partners for enhanced referrals. AGYW are the main target group for the DREAMS initiative and they are at increased risk of HIV as indicated by ZamPHIA. SAFE will ensure collection of data on PrEP users who continue at one and three months in the next quarter in order to give a full picture of retention status.
During the second half of FY19 (April-Sept 2019), 6,648 clients were found active on PrEP service (PrEP_CURR). This includes 5,322 clients newly initiated on PrEP and 1,326 continuing on PrEP prior to April. A total of 2,704 tested for HIV at three months post enrollment on PrEP and 47 (1.7% yield) were identified to be HIV positive with linkage rate of 62%. A total of 534 discontinued PrEP during the reporting period. CBVs followed up on clients who discontinued PrEP through home visits and phones calls and this data will be fully documented to site reasons why some individuals are discontinuing PrEP.
Cumulatively in FY19, USAID SAFE supported the initiation of 7,272 on PrEP, surpassing the annual target of 1,732 by over 100%
Challenges Reaching men through PrEP services is a challenge as men are known not to be active health seeking group like women. Some PrEP clients do not still understand the need for taking ARVs while on PrEP which may pose challenges with retention on PrEP.
Next Steps In collaboration with the MoH through G2G funds, SAFE will continue with classroom- based trainings and onsite orientations and mentorship for HCW and CBVs in all SAFE supported facilities. SAFE will develop and intensify appropriate messaging to target clients eligible for PrEP 21
through various media platforms. SAFE will prioritize activities that will help with the retention of clients and will provide health education messages to the clients on the importance of adhering to PrEP. SAFE will support the MoH to develop, print, and distribute IEC materials, job aids, and manuals for PrEP. SAFE will also provide support to ensure drugs are readily available by supporting facility-based drug forecasting, quantification, ordering and ordering.
TLD Transitioning
USAID SAFE continued supporting the MoH with the implementation of TLD transitioning. During the period under review, SAFE enrolled a total number of 21,071 clients on TLD. A total of 5,131 (24%) out of those enrolled were new ART clients and 15,940 (76%) were transitioned to TLD. More than half (11,266; 53%) of the total enrolled were men. Cumulatively, SAFE has enrolled a total of 84,655 clients on TLD in FY19 making it the highest number among all implementing partners in Zambia (see Figure 4).
Figure 4. Clients Transitioning to TLD by Age and Sex, FY19 (USAID SAFE) 22
During the period under review, SAFE supported the distribution of ART drugs for TLD transitioning to SAFE supported provinces, districts, and facilities. SAFE printed and distributed TLD transitioning IEC materials and job aids. SAFE worked with the PHOs and DHOs to develop recorded and live messaging programs on TLD to promote awareness amongst PLHIV. SAFE also implemented pharmacovigilance orientations and sent reports to the DHOS, PHOs, and ZAMRA on clients that were noted to have adverse effects on TLD. Four clients were managed with severe Dolutegravir drug reactions. All clients were put back on TLE and treated for Steven Johnson’s Syndrome. All fully recovered and were reported to ZAMRA.
It is worth highlighting that the introduction of TLD as the preferred first line drug also came at a time when there was a huge debate around safety towards the unborn babies in the first trimester, a finding that disadvantaged women of the reproductive age group. SAFE has worked very hard to ensure that no woman who opts for TLD is disadvantaged by ensuring that all women are exposed to modern methods of family planning and are given the opportunity to enjoy the actual service. With LARC modern methods of FP integrated in ART we have seen an exponential increase in the number of women who have now able to access TLD.
Because of the overstock of TLE in Q4, especially September, SAFE slowed transitioning of clients on TLD and continued enrolling eligible new clients on TLD. This is likely to continue in Q1 of FY20 as the challenges with TLE overstock remain and may only normalize in Q3 or Q4 of FY20. There is still an overstock of TLE and this will affect scale-up of TLD. The current guidance from the MoH is to hold on to the transition and only initiate eligible new clients on TLD. Copperbelt province overstocks from Northern and Eastern provinces which will further affect the duration to sort out the TLE and EFV overstocks.
Next Steps USAID SAFE will continue supporting the MoH on TLD transitioning through its 23
technical contribution on the TLD transitioning subcommittee under the National HIV TWG. USAID SAFE will ensure availability of TLD in all SAFE supported facilities through facility-based quantification and support to last mile distribution of TLD. SAFE will also intensify the integration of FP in ART services and will ensure that women of child bearing age have easy access to FP services and are counseled on their eligibility to be enrolled on TLD.
Sub-objective 2.3: 95% adults and children currently receiving ART are maintained on treatment Key Achievements TX_CURR annual target: 311,791 Quarter 4 achievement: 270,103 (87%)
At the end of FY19 Q4, the number of clients that were active on ART (TX_CURR) was 270,103. This shows a net new of 21,352 from 248,751 that was reporting in Q3. Intensive TSS and onsite mentorship on appointment registers and tracking of the Suspected Lost to Follow Up (SLTFU) clients contributed to this number. To reduce the number of LTFU clients, USAID SAFE continued to generate weekly lists of clients who were late to pick up their medications at the pharmacy. The facility team continued to evaluate this list to remove those who could have been missed in SmartCare against the “true” late and lost clients. Then the team would share this new list among CBVs and PCs to contact clients via cell phone and home visits.
The program ensures that counselors are mentored on the outcomes in the tracking tools to ensure that services are provided correctly and are fully documented. The team also encourages CBVs to ensure that they report tracked clients to SIAs so that client information can be updated in SmartCare and in-patient files. The program further received technical support in Q4 from JSI home office on M&E and programmatic implementation to strengthen systems in managing SLTFU. These included strategies such as calling clients prior to the appointment dates to confirm attendance and clustering of villages for identified SLTFU clients that CBVs could reach without transport. Teams on the ground understood and practiced these strategies, which have significantly reduced SLTFU.
Another contributor to the reduced LTFU in Copperbelt is the coordination with EQUIP for clients who access their medication from the Central Dispensing Unit (CDU) but are also enrolled with SAFE program. EQUIP is now sharing a list of active clients with SAFE on a weekly basis for updating in SAFE’s database. This is the reason for the reduced SLTFU in Ndola district. Additionally, during this reporting period, SAFE conducted a full physical count of all active clients on treatment, viral load documentation, and TB screening. As a result, more clients were added to TX_CURR through the updating of files which had not been updated in SmartCare.
The program has achieved 87% against set annual target of 311,791.
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In Q1 FY19, SAFE conducted a detailed analysis of provincial targets against then current TX_CURR values per facility as well as potential TX_CURR based on PLHIV estimates and outreach activities. This analysis, shared with USAID, revealed that there were 5 districts in particular, Masaiti, Chisamba, Serenje, Chibombo, and Chisamba, which had a significant disparity between the target and TX_CURR potential as informed by current activities. The variance in what SAFE believed to be the reasonable, expected achievement within these districts versus the assigned target was approximately 30,000 or nearly 10% of the total SAFE TX_CURR target for the COP year.
In agreement with USAID, SAFE conducted two major sweep activities. The main objective of the sweeps was to increase the coverage of targeted testing in the four districts, however other activities were incorporated due to increased coverage. These activities included; follow up of clients that once tested HIV +VE but were not initiated, collection of VL samples from all eligible clients, follow up of patients that missed their clinic contact and, tracking of exposed infants so that DBS could be collected. For the sweep activity, in Central Province, a total of 15411 clients were tested, out of which, 756 (5%) tested HIV +Ve and, 834 (110%) clients enrolled on cART. Enrollment on cART was more than 100% due to clients that tested HIV +Ve in the previously periods but only got enrolled on cART during the SWEEP period. Chibombo district had the most enrolments on cART with 588, while Chitambo recorded the lowest enrolments of 52 clients. Chisamba and Serenje enrolled 298 and 107 clients, respectively. Average Positivity Rate for all the four districts was 5%, whereas Chisamba, Serenje, Chibombo and Chitambo recorded 8%, 5%, 4% and 3%, respectively. Enrollments for Masaiti increased by 290 only.
Figure 5. TX_CURR: Clients currently on ART, FY19 Q4 (USAID SAFE 2019)
USAID SAFE has continued to ensure that at the close of every clinical day each facility generates a list of clients who missed their clinical appointments, which is shared with CBVs for immediate tracking. This ongoing exercise has resulted in the return of many clients to treatment (8,243 or 73.4% of 11,225 SLTFU across all three provinces). Counselors have been mentored on the tracking outcomes contained in the tracking tools to ensure accuracy and completeness of service provision. CBVs were also encouraged to ensure that clients tracked are reported to SIAs for updating in SmartCare to ensure they are included in TX_CURR. SIAs were mentored and supported on key registers including the community tracking and events tracking registers.
USAID SAFE continues to provide intensive mentorship activities in test and treat, defaulter 25 tracking by adherence counselors, and placement of SAFE-supported qualified clinical staff to provide DSD to manage clients receiving ART. TX_CURR will further be collected based on pickup intervals, that is, how many clients are picking up ART drugs on a quarterly, semi-annual, monthly, and annual basis.
Differentiated Service Delivery Models USAID SAFE continued implementing various DSD models including Multi-Month Dispensation (MMD) of both three and six-months, Community Adherence Groups (CAGs), and, in collaboration with EQUIP, Centralized Dispensation Units (CDU). USAID SAFE also implemented the weekend and after-hours model though at a very low scale. A total of 35,059 ART clients were on 6-month dispensation model as of end of September 2019; 61% (21,490) of females and 39% (13,569) of males. More effort will be done to ensure that clients are classified by 3-month, 3-5 months and 6-month dispensation models in the coming quarter, as per COP19 guidelines.
Strategies for retention among paediatrics: SAFE will replicate the strategies of intensive tracking of mother-baby pairing, building on the successes scored in areas where M2M has successfully implemented; Creation and strengthening of DSD models involving mother living in the same geographical needing similar support; Strengthening a family centered approach where the entire family is visited with ART services where parents and children are on ART
Strategies for retention among adolescents: Continue to bold capacity of health providers on age appropriate message for AGYW; Intensify youth friendly corners in high volume facilities which will ensure that youth are seen separately and that peers are motivated to encourage their fellow youth to seek services including ART; Start and intensify DSD model models for young people in selected communities; Work with other IPs to learn how they are using ICT e.g. CRS to promote good health seeking behavior among young people including attitudes and behaviors towards ART.
Challenges Not all facility in-charges understand the purpose of DSD models. To change this, SAFE provided orientation on DSD models for most of the in-charges. Disruption of the 6-months dispensation due to inadequate stocks of TLD and the TLE push by MoH. This has since been managed by ensuring that even with TLE and good expiry dates we can go ahead and fulfil the 6-months TLD dispensation. MSL did not deliver drugs to the facility per the schedule. This affected the enrolment of clients on the MMD model because of the non-availability of adequate drugs in the facility for implementation of DSDs. SAFE supported the MSL in the distribution of drugs to the facilities. The untimely updating of patient drug refills on the CDU contributed to the SLTFU of clients that were not really lost to care. SAFE collaborated with the EQUIP team to ensure that patient records were updated in a timely manner. 26
Next steps SAFE will continue supporting the MoH through its participation on the DSD task force under the National HIV TWG. I SAFE will continue to take the opportunity to influence policy on DSDs through this platform. SAFE will scale up other DSD models including the unsuppressed clinics, adolescent models, before hours, after hours, weekend models, and men’s clinics and will also implement the 3- and 6-months dispensation of TPT. USAID SAFE will work with the MoH, MSL, and PSM to ensure the availability of drugs for DSD implementation. At the facility level, USAID SAFE will continue to support the quantification of ART drugs for DSD implementation. SAFE will also continue providing intensive onsite supervision and mentorship on DSD implementation to facility-based staff. Through the PPP platforms, SAFE will also introduce the implementation of DSDs in the private sector.
Treatment, Mortality and Loss to Follow (TX_ML)
A total of 14,782 ART patients had no clinical contacts since their last expected contact in the last six months (April-September 2019). Of these, 10% (1,524) were reported to have died, 33% (4,830) self-transferred to other facilities, 42% (6,276) were tracked and could not be located, and 15% (2,203) were not tracked due CBVs inability to track them through phone calls or house visits. The program is using telephone calls to remind patients about their next appointment. This has helped reduce suspected lost to follow as some clients would request alternate dates based on their commitments. Additionally, the program engaged CBVs and PCs to ensure that immediate tracing happens. Tracing of clients who missed appointments takes place within a week of missed appointment by CBVs through home-visits and phone calling. This resulted in improvement in retention and documentation of outcomes for those missing appointments.
Management of TB/HIV
TB Screening A total of 217,662 ART clients were screened for TB during the reporting period (April- September 2019). This includes 10% (22,363) who were newly enrolled ART clients within the last six months as well as 90% (195,299) previously started on ART prior to April 2019. Eighty- one percent of all active clients on ART were screened for TB, including 87% (10,490/11,999) of children below 15 years and 80% (207,172/258,104) of adults aged 15 years and above. The presumptive TB rate was 4.2% (9,062/217,662) and 50% (4,527) of specimens were sent for bacteriological diagnosis of Active TB disease. About 46% of specimen were sent for GeneXpert, 50% for smear microscopy, and only 4% sent for other diagnosis. The reasons why not all ART clients were not screened for TB was as a result of some clients sending treatment supporter to collect their medication and hence affected the physical count. Additionally, there were clients who were in fishing camps especially in Central province and could not be counted even though they had enough drugs. 27
Implementation of TPT (TB_PREV) During the past six months (April-September 2019), 3,214 (29%) clients completed TPT from a total of 11,079 expected to complete their treatment. Low TPT stock levels in-country have resulted in these low completion rate. Mitigating measures are underway: USAID SAFE supported MoH to procure 65,000 *100 Pyridoxine tablets (Vitamin B6) out of which 30,000 *100 tablets have been delivered to health facilities as we await receipt of remaining 35,000 * 100 tablets. The support was provided to avert stock challenges at the central and health facility levels. USAID SAFE supported the MoH in the launch and dissemination of the current TPT guidelines and conducted provincial, district, and facility-based orientations. USAID SAFE also provided onsite supportive supervision and mentorship on TPT. In addition to the supporting the MoH on the procurement of drugs required for TPT implementation, USAID SAFE also supported the distribution of TPT drugs from MSL to SAFE- supported provinces, districts, and facilities. The total achieved throughout FY19 represents 19% (4,254) achievement towards the annual target of 21,959. Challenges Non-availability of drugs required for TPT implementation. Both Isoniazid (INH) and Vitamin B6 were out of stock in most facilities which led to USAID SAFE not achieving the targets on TPT implementation. USAID SAFE made efforts to procure INH and Vit B6 but the TAT for delivery from the manufacturers more than 12 weeks, which did not help much in supporting the stock out of the drugs. Next steps SAFE will continue to provide intensive onsite support on the quantification of drugs required for TPT at facility level to ensure that all clients started on TPT complete the six-months regimen. SAFE will continue to provide mentorship on the identified challenges on documentation in the TPT register which may affect the numbers reported. SAFE also conducted DQAs that include data on TPT. During the period under review, SAFE ensured that TPT implementation was part of the data review meetings at facility, district, and provincial levels. Messaging on TPT was included in the recorded and live radio programs that SAFE developed in collaboration with the PHOs and DHOs. Intensive orientations, supervision, and mentorship to all facility based HCWs and CBVs on the implementation of TPT through on-going monitoring of daily/weekly progress. SAFE will also conduct surges in Q1 and Q2 to ensure that 50% of the TX_CURR is initiated on TPT by Q2 of FY20 in order for the clients to complete TPT by Q4, again this is dependent on stock availability through MSL. Through the PPP platform, SAFE will support the implementation of TPT in the private sector.
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Sub-objective 2.5: 14,762 HIV-positive pregnant women received ART to reduce the risk of mother-to-child-transmission during pregnancy Key Achievements PMTCT_ART annual target: 14,762 Quarter 4 achievement: 2,996 ART coverage rate: 93% Cumulative achievement: 12,727 (86%)
During FY19 Q4, 2,996 HIV-positive pregnant women were receiving ART: 69% (2,078) of these were already on ART prior to ANC and 31% (918) were newly initiated during ANC. The ART coverage rate increased slightly from last quarter, 92% to 93%. Copperbelt province had the highest ART coverage rate of 94%; Central was 91% and North-western achieved 89%.
Cumulatively in FY19, USAID SAFE supported 12,727 HIV positive pregnant women to receive ART, representing an achievement of 86% of the annual target of 14,762.
Figure 6. PMTCT_ART: Pregnant Women Initiated on ART, by Quarter (USAID SAFE 2019)
Cervical Cancer Screening
Enhance screening of cervical cancer for all newly initiated HIV-positives within the ART clinic for early diagnosis and management of CaCx
The USAID SAFE program continued to offer cervical cancer screening and treatment to HIV positive women on ART. The focus has been on those aged 25-49 years but services are offered to every woman who was on ART. For the second half of FY19 (April-September 2019), the program screened 29,402 HIV positive women on ART. The target audience of 25- 49 years constituted 89% (26,152), followed by those aged above 50 years, at 8% (2,249) and lastly those aged below 25 years at 3% (1,001). The last six-month results showed an upward trajectory from the first six months (October 2018 to January 2019); 549% increase from 4,529 to 29,402 among all HIV positive women on ART screened for cervical cancer. The services 29 provided included demand creation through the distribution of IEC materials, radio messaging programs, intensified TSS, and capacity building for MoH service providers.
Whilst a huge upward trajectory was observed in terms of screening women for cervical cancer, USAID SAFE faced many challenges encouraging HIV-positive women on ART to get screened for cervical cancer. Most of the women on ART shied away from accessing the service citing that the community was fully aware that they are the targeted group for cervical cancer screening and as such, they avoid being seen entering the cervical cancer screening room for fear of being identified as being HIV positive. Counselling of women on ART was intensified ensure that they understand the benefits of being screened for cervical cancer.
In the second half of FY19 (April-September 2019), of the 29,402 women on ART screened for cervical cancer, 7% (2,087) had positive VIA results. A total of 1,131 (54%) of VIA positive women were treated with cryotherapy, thermal coagulation, or LEEP. Of all women treated, half (50%) were treated with LEEP followed by 30% treated with thermal coagulation and only 21% treated with cryotherapy. The Single Visit Approach has been very slow as most women preferred consulting their spouses before commencing treatment. As a result, the majority of women did not return for treatment which contributed to the low treatment rates. Additionally, the low treatment may be attributed to the lack of equipment and supplies in facilities. SAFE will increase the number of treatment centers and will also procure equipment required for treatment. SAFE will further put in a place an active follow up program for clients that were not treated. Inadequate documentation was also cited as one of the contributing factors as most facilities were still using improvised registers. USAID SAFE has printed and distributed registers to address this shortage. In addition, SAFE also started providing onsite mentorship to both SIAs and cervical cancer providers to improve on documentation. Table 3 represents cervical cancer facilities and treatment services offered.
Table 3: Cervical Cancer Sites by Treatment Type; FY19 Q4 (USAID SAFE 2019) Copperbelt province # Name of Facility District CaCx Treatment Type VIA, LEEP, both Cryotherapy and Thermo- 1 Ndola Teaching Hospital Ndola coagulation 2 Twapia clinic Ndola VIA and Thermo-coagulation 3 Lubuto clinic Ndola VIA and Thermo-coagulation 4 Mapalo clinic Ndola VIA and Thermo-coagulation 5 Chipokota/Mayamba clinic Ndola VIA and Thermo-coagulation Nchaga North General VIA, LEEP, both Cryotherapy and Thermo- 6 Chingola Hospital coagulation St. Theresa Mission 7 Mpongwe VIA, LEEP and just Cryotherapy Hospital 8 Mpongwe Mission Hospital Mpongwe VIA and Thermo-coagulation VIA, LEEP, both Cryotherapy and Thermo- 9 Kitwe Teaching Hospital Kitwe coagulation 10 Chimwemwe clinic Kitwe VIA and Thermo-coagulation 11 Buchi clinic Kitwe VIA and Thermo-coagulation 30
12 Ndeke clinic Kitwe VIA and Thermo-coagulation 13 Luangwa clinic Kitwe VIA and Thermo-coagulation 14 Chaisa Sec. 9 clinic Luanshya VIA and Thermo-coagulation 15 Chambishi Gov. Clinic Kaluluishi VIA and Thermo-coagulation 16 Chawama clinic Chingola VIA and Thermo-coagulation 17 Lubengele clinic Chililabombwe VIA and Thermo-coagulation 18 Ronald Ross Hospital Mufulira VIA and Thermo-coagulation Central province # Name of Facility District CaCx Services Provided 1 Ngungu Kabwe VIA and Thermo-coagulation, 2 Kabwe Central Hospital Kabwe LEEP 3 Chibombo health centre Chibombo VIA and Thermo-coagulation 4 Liteta hospital Chibombo VIA and Thermo-coagulation 5 Serenje hospital Serenje VIA and Thermo-coagulation, LEEP 6 Mumbwa district hospital Mumbwa VIA and Thermo-coagulation, LEEP 7 Chisamba clinic Chisamba VIA and Thermo-coagulation 8 Kapiri Urban Clinic Kapiri Mposhi VIA and Thermo-coagulation, Cryotherapy, LEEP North-western province # Name of Facility District CaCx Services Provided 1 Solwezi General hospital Solwezi VIA and Thermo-coagulation, LEEP 2 Solwezi Urban centre Solwezi VIA and Thermo-coagulation 3 Kimasala health centre Solwezi VIA and Thermo-coagulation Lumwana District 4 Kalumbila district hospital VIA, Thermo-coagulation, Cryotherapy Hospital
Cumulatively in FY19, USAID SAFE supported screening of 33,931 HIV positive women on ART, achieving 52% of the annual target of 65,000. The program did not meet the annual target because USAID SAFE’s Cervical Cancer Screening program faced challenges in the start-up phase and first year of implementation of the program on the project. The challenges to the program were primarily because of the low service coverage in the SAFE-supported provinces. There are currently 28 facilities that offer cervical cancer screening services across the three SAFE-supported provinces. At the beginning of the program, the screening program was non- existent and SAFE supported the reactivation of all 28 screening facilities/centers. Additionally, the program only started in February/March due to delays in startup.
Challenges Inadequate providers to implement the program. At the beginning of the program there were challenges with the availability of providers. The providers that were trained under CIDRZ were either not providing the services or were moved to other departments within the facilities or to other districts or outside the province. SAFE trained 64 providers across all three SAFE-supported provinces. Despite the addition of new providers, there is high staff attrition. SAFE engaged the PHDs in the SAFE-supported provinces to fully support the cervical cancer program and to put in measures to mitigate the high attrition rate among the providers that have been trained. The cervical cancer screening is highly specialized and requires that the newly trained 31
providers have intensive mentorship and there are not enough mentors in the program. SAFE worked with the PHOs to identify specialists in the province who will provide the supportive supervision and mentorship along with the SAFE supported staff. Setting up of new screening and treatment centers is not an easy task as it requires an intensive procurement process for the equipment and consumables necessary for the program. SAFE worked with MoH and other implementing partners to ensure that the procurement process was less complicated. However, the procurement is highly specialized and vendors and manufacturers of cervical cancer equipment are limited at all levels. There are only two manufacturers for the highly specialized equipment used in the screening program. Going forward, SAFE will work with the identified vendors for the equipment and consumables to ensure that activities run smoothly.
Next Steps In FY20 Q2, USAID SAFE will scale up the cervical cancer screening services from the current 27 screening facilities to 50. The treatment facilities for LEEP will be scaled up from 8 to 24 to ensure wider coverage. In FY20 Q2, SAFE will train more VIA and LEEP providers and aims to have three VIA and three LEEP providers at each VIA and LEEP facility. SAFE will conduct QA/QI checks and projects in the supported facilities to ensure that the screening is of quality. SAFE will support train provincial and district mentors for the program that will work with the providers at facility level. USAID SAFE will support the procurement of commodities and consumables required for the screening services in the facilities. SAFE will also support facility-based quantification for the commodities and consumables
Objective 3: Ensure that 95 Percent of Those on ART are Virally Suppressed Sub-objective 3.2: 95% of ART patients with viral load result documented in the medical record and/or laboratory information system within the past 12 months with a suppressed viral load.
Key Achievements Viral tests conducted annual target: 310,969 Quarterly achievement: 186,424 (60%) Virally suppressed in Q4: 167,971 (90%)
During FY19 Q4, 186,424 ART clients had viral load (VL) results documented in their patient file within the last 12 months. This represents a crude estimate of VL coverage at 79% of Q2 TX_CURR (234,883). North-western had the highest VL coverage of 91% followed by Central with 79% and lastly Copperbelt recorded 78%. The reporting quarter was characterized by increased client tracking including the generation of clients due for VL via SmartCare and manual patient file separation for those due to draw VL (orange sticker), unsuppressed VL (red sticker), and suppressed (green sticker) in all supported facilities. The creation of viral load 32 teams consisting of VL Clinicians, SIAs, CBVs, and PCs helped to zero in on clients as the teams went out into the community for follow up. Using locator information, all due clients and unsuppressed with registered phone numbers were called in for blood draws.
The overall suppression rate achieved was 90% (167,971). There was slight variation observed by province with North-western recording the highest suppression rate at 91%, followed by both Central and Copperbelt at 90%. There was little difference by gender, with females showing suppression rate of 91% compared to 89% of males. By age, children below 15 years had low viral suppression rate (see Figure 7). SAFE will support pediatric trainings, adherence counselling, use of EAC materials right from initiation and at all times follow up on clients. All facilities will assign either the HCW or CBV to a pediatric client for follow up on adherence support.
Eighty-four percent of unsuppressed clients had documented EAC done within the reporting period. All efforts continue to track unsuppressed clients for EAC sessions and further to index the sexual contacts.
USAID SAFE achieved 60% against the annual target of 310,969 for number of individuals with a viral load result documented (TX_PVLS_D). The annual target for individuals with a suppressed viral load was achieved (90%).
Figure 7. Percentage of Clients with Suppressed Viral Loads, FY19 Q4 (USAID SAFE 2019)
Viral Load Turn Around Time and Sample Chain of Custody USAID SAFE finalized the contract for e-Labs with Mezzanine, Africonnect, and VodaCom. 33
Training commenced in Q3 and final implementation was in Q4 with Copperbelt and Central provinces going live. A total number of 91 facilities were activated and monitoring of sample movements is now possible via the system including the electronic transmission of results via handsets. Overall turnaround time of results has reduced from two-three months to one-three weeks which is a phenomenal improvement. MoH placed two high throughput analysers at Kabwe Central Hospital and Solwezi General Hospital to improve on viral load productivity for Central and North Western provinces.
Improving access to viral load testing USAID SAFE concentrated its efforts in Central Province by facilitating the setting up of a PCR Lab in Serenje upon request from the MoH. This request was prompted by the long distance’s sites in the Serenje catchment had to cover to reach Kabwe with referred samples for viral load testing. The lab was finally completed in August 2019 but minimal testing has occurred due to the excessive number of power cuts experienced. USAID SAFE is supporting the lab with back- up power solutions and the situation should stabilize by Q1 of 2020. USAID SAFE equipped the lab with the following:
1. Biosafety Cabinet 2. Triple glass door merchandiser fridge 3. 5KVA UPS 4. Ultra-Low -80 Freezer 5. Air conditioners 6. Window Blinds 7. Porcelain sink
USAID SAFE also equipped the newly modified lab space at Arthur Davison Children’s Hospital for the sophisticated very high throughput PCR analyser Cobas 6800. Procured and installed were the following:
1. Ultra-Low minus 80 freezer 2. Biosafety Cabinet 3. 48,000 BTU air conditioners 4. Triple glass door merchandiser refrigerator 5. Access Control
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HIV treatment cascade
Figure 8. HIV Testing, Positivity, and Initiation on ART, FY19 Q4 (USAID SAFE 2019)
Objective 4: Strengthen the Health System to Support the Objectives of 95/95/95
In Q4, USAID SAFE supported MoH in the implementation of multi-month dispensations by facilitating ARV movement from regional medical stores hubs and district health offices to Service Delivery Points, thereby improving stock availability. In order to improve supply chain and pharmaceutical documentation at the facility level and enhance multi-month dispensation, USAID SAFE deployed 65 pharmacy staff (34 in Copperbelt, 27 in Central, and 4 in North- western province) in high volume facilities. USAID SAFE has continued to support MoH in the implementation of TPT through procurement of 65,796 *100 Pyridoxine tablets (Vitamin B6) out of which 30,000 *100 tablets have been delivered to health facilities as we await receipt of remaining 35,796 * 100 tablets. The support was provided to avoid stock challenges of this product both at central and health facility levels. 35
To build capacity of health care workers, USAID SAFE conducted a three-day Pharmacovigilance training in Mufumbwe District of North-western Province for 34 health workers (19 males and 15 females). In order to ensure commodity accountability through improved data and commodity management at facility level, USAID SAFE supported MoH to conduct a pharmaceutical commodities audit trail. A total of 71 facilities (41 in Central and 30 Copperbelt Province) were audited. The audit showed no use of internal supply vouchers in some facilities to account for commodities (drugs and other medical supplies) issued to departments within facilities. Additionally, the updating of Stock Control Cards (SCC) and Goods Received Notes (GRNs) was not timely done leading to challenges to account for commodities received from MSL. The audit findings will be used as a basis for facility technical supervisory support prioritization. Challenges Stock outs of INH tablets at Central level affecting stock availability at facility level hence continued TPT implementation challenges. Low stocks of ARVs due to delay in delivery by MSL. USAID SAFE has continued to facilitate the distribution from regional MSL hubs and district health offices to facilities thereby enhancing commodity security. Next steps Enhance implementation of TPT through procurement of Isoniazid tablets. Continuous monitoring of stock levels at service delivery points and facilitating redistribution to facilities with low stocks. Support MoH with the last mile distribution of drugs and medical supplies to avoid stock challenges at service delivery points as a result of delayed deliveries.
Demand creation through the use of community radio stations in collaboration with ZAMCOM During the period under review, USAID SAFE, in partnership with Zambia Institute of Mass Communication (ZAMCOM), engaged MOH in North-western, Central, and Copperbelt provinces to roll out the community radio programs. These programs aimed at increasing the uptake of HIV services in the provinces of implementation. The series of programs was developed targeting the various groups who most require the services provided. In North- western province, a series of radio programs on topics such as HIV testing and self-testing, early infant diagnosis, ART initiation and retention on treatment, viral load suppression and testing, cervical cancer, Pre-Exposure Prophylaxis, and nutrition were broadcasted. Program participants included MOH experts, community volunteers, and health care providers. These teams were identified by the Provincial Health Offices in collaboration with the Provincial Health Promotion Officers. The community radio programs were a combination of pre- recorded segments and discussion programs that allowed the general public to talk about the issues and address their questions and concerns. Some of the notable achievements of these programs included: Raised awareness of HIV testing services offered in public health facilities. Improve uptake of the HIV testing services offered in public health facilities. 36
Provided accurate information on HIV, ARVs, family planning, VMMC, nutrition for people living with HIV, and cervical cancer screening and dispelled myths that existed. Furthermore, visits were also made to Central and Copperbelt to commence the radio programs. A schedule has been developed and implementation continues in October 2019.
Objective 5: Provide Voluntary Medical Male Circumcisions to Priority Populations to Avert New Infections
Key achievements VMMC annual target: 61,190 Quarter 4 achievement: 26,460 Cumulative achievement: 84,259 (138%) Number aged between 15 and 29 to date: 61%
During FY19 Q4, 26,460 clients were circumcised through surgical technique contributing to the achievement of 173% of the quarterly target of 15,297. USAID SAFE surpassed the quarterly target due to intensified demand creation during the winter season and school breaks made it easier to engage with school boys during mobilization. Additionally, USAID SAFE collaborated with the MoH and other IPs to support the launch of the August National VMMC campaign. This quarter achievement marks a 57% increase from the previous quarter.
Sixty-one percent (16,113) of MC clients were in the age group of 15-29 years followed by boys aged 10-14 years at 30% (8,006), and lastly those aged above 30 years contributed 9% (2,342). The 61% of those aged 15-29 years is in alignment with PEPFAR recommendations and the program was able to mobilize for this age band using community leaders and promotion through community radio stations conducted in conjunction with MoH. The program also supported August school holiday campaigns, both static as well as outreach activities, in the 82 VMMC facilities to improve access to services for boys and men during the August holiday when schools were closed. This resulted in 3,951 clients (contributing 15% to the total MC) being reached through mobile outreach in all three provinces.
The majority of MC clients were reached in Copperbelt with 65% (17,131), exceeding the quarterly target of 5,548 by over 100%, followed by Central with 34% (9,009), achieving 196% of quarterly target, and lastly North-western with only 1% (320). North-western did not have target for VMMC, hence resources were directed to other health areas. The program continued to provide a comprehensive package for MC clients and, as a result, 72% (18,933) were provided with testing services on-site before the MC procedure. Seven clients were newly diagnosed as HIV positive with a yield of 0.04% and all were linked to care and treatment. The majority of clients (18,928) were found to be HIV negative during the on- site testing. Additionally, a majority of clients not tested on-site (7,527) had documented recent HIV status or were already on ART, and some were not eligible for testing based on the use of HIV screening tool.
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USAID SAFE worked very closely with MoH at the national and provincial levels by attending monthly TWGs meetings. These meetings provided a platform for influencing policy formulation and sharing of best practices among IPs. As a result of such collaborations, USAID SAFE began implementing the use of HIV screening tools in VMMC with the view of embracing smart testing. This resulted in 72% of MC clients being tested in this reporting quarter compared to 79% testing rate experienced in the previous quarter. All MC clients returned at least once in 14 days for follow up care. USAID SAFE supported a total of 84,259 MC procedures in FY19, marking 138% achievement of the annual target of 61,190 (see Figure 9).
Figure 9. VMMC_CIRC: Number of Males Circumcised, by Quarter (USAID SAFE 2019)
High-impact interventions During the quarter under review, the program offered monthly mentorship and TSS to about 60% of the VMMC facilities in program districts. The focus was mainly on addressing some of the identified gaps from the EQA report, strengthening QA/QI committees, onsite orientation of hygiene assistants and EHTs in infection prevention and health care waste management, and data quality and use. Two data review meetings were held at two facilities in Copperbelt province. The program conducted mentorship for 80% of the providers who underwent refresher trainings in the previous quarter. As a result, fewer AEs were reported in this quarter as compared to Q3, from 780 to 660. Majority were infections due to personal poor hygiene by clients, a few minor bleeding and hematomas. They were attended to promptly without any complications.
The program strengthened collaborations between MoH and private institutions including higher institutions of learning with the view of scaling up VMMC activities in the private sector. The program supported the starting of VMMC service provision at Zambian Breweries where the first four employees were circumcised in collaboration with Zambian Breweries Health Care Staff and the providers from the district. The program supported community initiatives by working with school head teachers and guidance affairs officers in institutions of higher learning to increase MC demand. Health talks in three higher learning institutions (Malcom Moffat College of Education, Mulungushi University, and Nkumbi International School) were held.
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The MC team after the inaugural circumcisions at Zambian Breweries and Sensitization meeting for first year student at Mulungushi University.
During Q4, USAID SAFE continued providing health care providers with stipends and allowances to allow them to work an extra shift during the week or weekend in order to improve access to male circumcision services. The program also continued to provide transport and fuel to conduct services through mobile and outreach sites, especially in the hard-to-reach areas such as Ngabwe and Luano sites.
The program also participated in the review of the National VMMC strategic plan and sustainability strategy, which resulted in refining some of the strategies beyond 2020. In order to ensure consistent supply of MC consumables and avoid interruption of MC services, the program procured and delivered 23,000 VMMC kits to USAID SAFE-supported VMMC facilities. Furthermore, the program procured and distributed 30,000 client intake forms to SAFE-supported facilities. In addition, SAFE facilitated the distribution of 7,700 vials of lignocaine from MSL to SAFE-supported provinces.
Challenges: 1. Inadequate infrastructure to support all required VMMC services within proximity. This compromises patient flow between theatre and HTS activities. 2. Power outages affect sterilization of instruments and contributes to poor lighting in some facilities. 3. Inadequate equipment such as pediatrics BP machines, adjustable theatre beds, ambu bag, and tents to support mobile or outreach activities. 4. Erratic supply of Lignocaine and Panadol during the quarter affects smooth running of the program. 39
Objective 6: Integrate Family Planning Services into 95 Percent of HIV Service Delivery Locations
Key Achievements Number of facilities with integrated family planning services: 270 Number of service delivery points with integrated family planning services: 1,072 Number of ART clients provided with at least one method: 8,621
Out of all supported facilities, 270 had family planning services during Q4 with a total of 1,072 service delivery points that had integrated family planning service. The service delivery points include ANC/MCH, Care & Treatment and HIV testing points. The USAID SAFE program continued to provide contraceptives as part of integration into HIV/AIDS services in all three supported provinces of Central, Copperbelt, and North-western. During Q4, 91,665 females and 968 males were reached with counselling and provision of contraception. The 91,665 females included 80% (73,192) who were return clients and 20% (18,473) who were new clients (first acceptor). About 64% (58,884) of contraceptive users were adults above 25 years while AGYW constituted 36% (32,781). The highest number of contraceptives was provided in Copperbelt with 57% (52,649), followed by Central with 34% (31,486), and North-western at 8% (7,530). A total of 968 men were reached exclusively with condoms and messaging on FP. Of all hormonal contraceptives distributed, Depo-Provera (61%) was most popular followed by Implants-Jadelle at 15%. Other hormonal contraceptives constituted less than 14% (see Table 4). All contraceptives distributed were obtained through the DHOs in the respective provinces. Table 4. Distribution of Contraceptives, FY19 Q4 (USAID SAFE 2019) Contraceptive method Number of females served % of total female served Combined Oral Contraceptives 10,591 12% Progestein only Pills 3,611 4% Depo-Provera 56,058 61% IUD 2,688 3% Implants-Jadelle 13,737 15% Noristretate 4,980 5% Total 91,665
Contraceptive and HIV/AIDS Integration During the quarter, USAID SAFE provided support to selected districts and facilities in Central, Copperbelt, and North-western provinces. SAFE continued consolidating and integrating services to assure a seamless delivery of a comprehensive package to clients accessing RH/FP and HIV services in SAFE-supported facilities. Activities aimed at increasing service delivery points in all facilities were carried out so that clients accessing FP and HIV services can access these services within ART clinics or OPD where space allows and not only rely on the MCH department. This was achieved through onsite knowledge and resource sharing relating to RH/FP and HIV integration with emphasis on correct documentation, data capture, and reporting. In this reporting period, 75% of new FP clients referred to testing services were tested and provided with results (see Table 5). HIV testing among new FP clients contributed 40
4% of the overall testing in this reporting period. Providers were also referring ART clients to FP services and 8,621 ART clients received FP services. Efforts will be strengthened to ensure successful referrals of HTS clients and FP services through integration of services as providers are also trained to provide testing services. This will be facilitated through on-going mentorship and on-site supervision by MoH staff with support from SAFE. Table 5. Family Planning Achievements, FY19 Q4 (USAID SAFE 2019) Indicator Results # of New FP clients referred for HTS 8,893 # of New FP clients provided with HTS 6,656 (75% testing rate) # of ART clients provided with at least one FP method 8,621 # of HTS clients referred for FP services 1,404
Key activities and major achievements for reporting period include the following: Reached 221 providers in Central province, 808 providers in Copperbelt province, and 35 providers in North-western province with technical assistance. Private facilities were provided with onsite mentorship and job aids and other tools to support the implementation of integrated services. These include integrated FP registers, FP Cards, MEC wheels, FP counseling tool kits, and pregnancy checklists. Twenty-two health care workers in Copperbelt and 19 in Central province were trained in LARC and integrated services. Provided follow up to newly trained providers to strengthen their skills in LARC and integration activities. Results from these efforts are beginning to show. MoH announced at a data review meeting that data from SAFE-supported sites was above 85% which is well above the national average. USAID SAFE supported MoH to review the family planning counseling tool kit to incorporate FP integration material and newer contraceptive methods. Participated at national monthly FPTWG meetings and continued to contribute in the DMPA and CBD task force sub-committee meetings. Participated in planning for year three SAFE project activities and forecasting procurement of equipment and tools under objective 6. Conducted joint monitoring and mentorship visits with DHO involving facility based champions in North-western, Copperbelt, and Central provinces SAFE conducted advocacy to ensure all key staff in SAFE HQ and provincial offices went through the 2019 online FP and HIV course. This initiative was escalated to ensure that facility level FP and HIV providers and supervisors were trained followed by on spot checks that were carried out carried out to monitor compliance with regard to clients’ freedom of choice regarding FP methods, no-cohesiveness practices and not use USG funds to conduct abortions Distributed MEC Wheels, FP Counseling Kits, pregnancy checklist, FP cards, and integrated FP registers Trainings are planned for year 3 for CBVs in order to strengthen their skills in the integration of FP services at community level and ensuring effective referrals to facility
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Private Sector Engagement: Overview USAID SAFE is working with the private sector to accomplish HIV/AIDS prevention, care, and treatment goals. The project envisions a responsive private sector providing integrated quality HIV services thereby contributing to improved private sector productivity and quality of life for PLHIV. The project engages with private entities that can be broadly categorized as health- based and non-health based. Health-based private sector entities include private clinics, hospices, private practitioner’s associations, and private health institutions of higher learning. Non-health based private health sector entities include mining companies, farms, cement companies, and brewery industries.
Public-Private Partnerships under USAID SAFE Project In the quarter under review, the project prioritized quality improvement in ART services in selected high-volume private health facilities. The program targeted three private hospitals, one in Copperbelt and two in North-western, all managed by Mary Begg Hospitals (a franchise of private hospitals subcontracted by First Quantum minerals). As of 30 September 2019, Mary Begg Hospital in Copperbelt had been assessed by HPCZ with a 99% compliance rate and was therefore accredited as an ART site. The ART accreditation process, which is overseen by the HPCZ, involves the systematic, multidisciplinary inspection of the physical and organizational structure of the facility and the functioning of its component parts. Parameters measured include leadership and governance, guidelines, SOPs and Quality Assurance, laboratory services, health information management, pharmaceutical management, and logistics among other things.
Using the same standards provided by HPCZ, USAID SAFE provided rigorous technical support to Mary Begg hospital in Ndola. This technical support included a mock accreditation exercise, supply of data management tools and mentorship on their use, and capacity building of ART staff through clinical symposiums. Later, HPCZ was invited to conduct a formal assessment, whose results revealed a 99 percent compliance rate to set quality standards. A schedule has already been agreed on with HPCZ for Mary Begg Hospitals in Solwezi and Kalumbila to go through a similar process in the next quarter.
The project continued to build the capacity of private health facilities to contribute towards attainment of the 95-95-95 goal. An onsite NACS training was conducted for 10 participants drawn from three Mary Begg Hospitals. Participants were provided requisite job aids and registers, and follow-up mentorship will be conducted in the next quarter.
In addition, onsite mentorship in family planning integration was conducted to 76 providers in 12 private health facilities in Copperbelt province. The mentorship exercise focused on the Medical Eligibility Criteria (MEC) wheel, family planning integration registers, FP counseling kit, and checklist to rule out pregnancy.
The project partnered with Northern Breweries in Ndola to provide Voluntary Male Medical Circumcision (VMMC) to employees. In order to avoid disruptions to production due to medical leave (to allow for wound healing) given after a VMMC procedure, a weekly schedule was developed. Twenty-seven clients were booked for VMMC, and four have since been circumcised.
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Challenges High staff turnover in private facilities affected continuity of activities. Often, staff in private facilities are employed on a part-time basis leading to high turnover. It is therefore challenging to see results from mentorship efforts, as mentored providers may have left by the time of the next visit by project staff.
Next steps The project has since used the PPP Forums to register this challenge with private facilities and representatives from the DHO. Most private facilities are now engaging retired nurses to mitigate staff turnover The program will prioritize reaching men with HIVST in places of work. The program will further work with selected private companies to train peer educators through a cost-sharing model. Through these peer educators, the program will seek to integrate distribution of HIVST kits into existing work place health and safety committees
Objective 7: Reach 90 Percent of Eligible HIV-positive Adults and Children with NACS
Key Achievements Number of sites integrating NACS in HIV services: 209 Number of ART clients assessed for nutrition: 127,370 Rehabilitated 49 malnourished clients in September
A total of 127,370 PLHIV were assessed for nutrition using anthropometry assessment in Q4 in 209 facilities that have integrated NACS in HIV services. A majority of clients assessed for nutrition were adults above 30 years, 73% (93,088), followed by those aged 15-24 years, 21% (26,934), and lastly children below 15 years at 6% (7,348). Among all clients assessed, 8% (10,660) were identified as being malnourished; 56% (5,929) were female and 44% (4,731) were male. Of all clients identified as being malnourished, 2,745 received packets of High Energy Protein Supplement (HEPS) and 373 received Ready-To-Use Therapeutic feeds (RUTF). Nutrition counseling and education was also provided to the 127,370 people assessed for nutrition. Of these, the 10,660 malnourished clients received one-on-one counseling. At the time of reporting, 244,200 sachets (92 grams) of PlumpyNut®, a RUTF for treating clients with severe acute malnutrition and 91,000 (1 kilogram) packets of HEPS, a fortified blended food (Corn-Soybean) to treat moderate acute malnutrition (MAM), were distributed to the high-volume sites. Dispensation of these commodities started in August. Of the 2,745 MAM clients who received HEPS in Central and Copperbelt, 49 were rehabilitated to normal nutritional status and discharged from the program by end of September.
NACS Training and Orientation Eight three-day trainings in OPD management of malnutrition and supply chain management were held in Ndola, Kabwe, Chingola, Chibombo, Kapiri Mposhi, and Mumbwa. These trainings 43 focused on assessing, diagnosing, and managing acute malnutrition; developing nutrition care plans (NCPs); managing the supply chain for specialized foods; using innovative methods to track lost to follow-up clients; and CBVs monitoring and following-up with clients on specialized foods in the community. Resource materials adapted by the project were used to supplement the MoH package of resources and enhance quality of the training. The trainees consisted of 340 healthcare workers (125 males; 215 females).
Additionally, one-day onsite orientations were conducted for 60 (25 males and 35 females) in four health facilities in Solwezi district of North-western province. The focus was the same as the three-day trainings, but the content was condensed.
Some agreed-upon action points to address the existing gaps were: Continued onsite orientation to strengthen NACS integration and proper use of specialized feeds. Separating drawers for patient files based on specialized foods will lessen delays when clients return for revisits. NACS focal point persons must ensure correctness and completeness of documentation of NACS data in patient files and NACS register. USAID SAFE and PHO must strengthen peer-to-peer mentorship. This will not only strengthen NACS integration and implementation, but also empower service providers and lead to program sustainability. CBVs must be fully engaged in providing NACS activities at facility and community levels because they are the cornerstone of HIV integration at the community level.
Mentoring All 85 sites receiving RUTF and HEPS were visited as part of continuous mentorship and on- going education. The focus was to ensure standards were followed on nutrition history taking, clinical examination and anthropometric measurements, prescriptions, and dispensing and documenting specialized feeds. Through exchange visits, HCWs from well performing districts and facilities mentored and shared best practices with their peers in poor performing sites. Some best practices exhibited in the reporting period were team work in HIV/NACS service delivery; ownership of NACS program by Ndola, Kitwe, Mkushi, Masaiti, and Kabwe districts where the district nutritionists conducted mentorship and supervision on their own; and the addition of CBVs not affiliated with USAID SAFE to assist with nutrition assessment and counseling.
Technical Supervision In addition to mentoring service providers, spot checks were conducted at each of the 85 health facilities to ensure secured rooms have ample space, are water proof, have pallets or shelves to store commodities securely, have good ventilation to keep commodities cool and dry, and there are no signs of pests/rodents. Supply chain documents for ordering, storing, and dispensing the commodities were also checked to ensure they were readily available. These included stock control cards, supply vouchers and nutrition support cards, ration cards, prescription forms, etc. Additionally, ART appointment registers were reviewed to ensure clients assessed for nutrition are documented correctly and completely in the malnourished register. All 85 sites ensure that 44 clients assessed for nutrition are entered in the register, and those not assessed are also recorded accordingly. Documentation in the NACS register remains a challenge in some sites, especially where NACS is left to a few individuals. New clinicians are not oriented upon arrival at some sites, and some sites (Lubengele, Chawama, Chiwempala, Mkushi Urban, and Masansa) have not fully integrated NACS in routine HIV services; hence, documentation in NACS registers and reporting is poor.
NACS Training for Kansanshi Mine health Centre The training was held at Kansanshi Mine Hospital 6 September, 2019. This training was a pre- requisite for the private hospital to be accredited. The training was attended by twelve (10) Kansanshi Mine employees. These were seven (7) Nurses, two (2) Medical Officers and one (1) counselor. Six (6) were from Kansanshi Mine Hospital, three (3) from Kabitata Clinic and one (1) from Trident Town Clinic (TTC). The three sites were given tools to enable NACS implementation such as Standard Operating Procedure Manual for NACS, NACS job Aids, Nutritional reference book, NACS training and tools for work.
NACS Integration Because of relentless capacity building efforts, all 85 health facilities are offering NACS routinely. NACS integration is visible at all NACS contact points along the client pathway. Each site has appointed a NACS focal point person who coordinates and supervises NACS activities and ensures integration is done. However, the levels of integration differ among the 85 sites. Clinics and health centers have fully integrated and synchronized most services as compared to hospitals. The complexity of hospitals has made NACS integration difficult in some sites. The disparity between number of people accessing ART and those nutritionally assessed is significant, while clinics and health centers have narrowed the gap. One of the reasons is that the leadership in clinics and health centers fully participate in service provision, which is not the case at hospitals. For example, at Arthur Davison Children’s Hospital, dispensing RUTF and HEPS through the pharmacy was rejected, and at Ndola Teaching Hospital, NACS documentation remains a challenge because all HCW trained in NACS do not work in the ART departments. Some clinics and health centers, such as Kansenshi Prison and Mapalo, also have had a challenging start to integrating NACS in routine HIV services until Q3 in year 2, despite their frontline staff being trained.
Although gains have been made in general ART, integrating NACS in Option B+ in MCH has been slower than expected. More coaching and mentoring will be done in the coming quarter so that clients on option B+ needing nutritional support are not missed.
NACS review and planning meetings To close the year, three NACS review and planning meeting were held in Kitwe, Chingola, and Ndola for 99 (17 males; 82 females) facility in-charges and NACS focal point persons from 52 high volume sites. Each health facility developed a six-month work plan for October 2019 to March 2020 based on the gaps identified.
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Table 6. Nutrition Achievements, FY19 Q4 (USAID SAFE 2019) Province # assessed # classified as # treated for # rehabilitated to for nutrition malnourished malnutrition normal nutrition status Central 54,712 3,282 1,011 28 Copperbelt 60,634 6,649 1,931 21 North Western 12,024 729 128 0
Challenges Some clients are not returning on scheduled review dates and some do not improve despite nutritional supplementation. Some health facilities, despite having staff oriented or trained in NACS, did not actively participate in implementing NACS, creating knowledge and skills gap in these facilities. Some health facilities are still struggling to offer NACS as part of HIV care, treatment, and support, hence the number of clients reached with nutrition assessment was far fewer than those who were assessed for HIV services.
Next steps Continue to provide on-the-job training, coaching, and mentoring of facility and community-based healthcare workers on the provision of NACS, especially on counseling and self-management. Provide coaching, mentoring, and on-the-job training to facility level staff on nutrition assessments and patient categorization for all clients that seek ART services. Develop and implement a community based matching program between community volunteers to NACS clients to improve adherence to care and treatment.
Early Childhood Development USAID SAFE supported the MoH on the ECD activities in 11 high volume facilities. This included the training of HCWs and CBVs using the MoH adapted training package for Caring for Child Healthy Growth and Development and the Standard Operating Procedure (SOP) manual for health institutions. The aim of the ECD program is to contribute to the holistic package of services designed to facilitate child development and support all multi-sectoral ECD nurturing activities in the Nurturing Care Framework. SAFE supported the MoH with the implementation of Early Childhood activities in Ndola (New Masala Clinic, Lubuto Clinic, and the Arthur Davison Children’s Hospital) and Kitwe (Buchi Main Clinic, Chimwemwe Clinic, and Ndeke Clinic), Kabwe (Ngungu Clinic, Katondo Clinic, Makululu Clinic, and Bwacha Clinic), Kapiri Mposhi (Kapiri Urban Clinic), and Chibombo (Chibombo Clinic). USAID SAFE trained 100 HCWs and 102 CBVs in ECD. The trained ECD staff spearheaded the implementation of ECD activities at the 11 SAFE ECD facilities. All ECD implementing sites have integrated ECD sensitization talks in their routine mother and child activities, including the ART program. The implementation of ECD in the ART program was done in collaboration with the mentor mothers in the facilities and the counselling sessions conducted using the MOH-approved 46 counselling cards and curriculum. The ECD play corners were operationalized at all 11 ECD facilities using locally available materials and toys. Space for ECD implementation was identified and is currently being used as play spaces/ECD corners. SAFE collaborated with the HCWs and CBVs to establish and operationalize the children play corners. This was done by leveraging the platform of existing community mobilization activities and engagements such as the Growth Monitoring and Promotion (GMP) activities Best practices: Maximization of key stakeholder buy-in by involving management and stakeholder orientation meetings. Integration of ECD activities into routine MCH activities and Growth Monitoring and Promotions as entry points for community ECD activities/play group formation. Use of locally available materials and collaboration with youth friendly corners to create new toys for ECD play corners promotes local sustainability. Documentation of ECD activities in ECD activity books and IEC registers (in absence of ECD specific registers). Provision of ECD IEC schedule of health talks has helped CBVs and HCWs package ECD content into easy concepts and key health messages in a systematic way over time.
Challenges Limitations with resources to convert play corners into child friendly spaces. Lack of MoH tools for tracking ECD specific activities (need ECD activities integrated into performance assessment tool for MOH)
Next steps Intensify the ECD services in the 11 existing ECD centers Integrate ECD activities into MoH performance assessment tool. It is recommended that USAID supports the revision of the MoH performance tool to integrate ECD activities Centrally support the roll out of ECD activities beyond the current 11 facilities supported by SAFE.
Management of Medical Waste In the period under review, SAFE supported facilities to manage different types of medical waste. SAFE has an Environmental Mitigation and Management Plan (EMMP) which provides a general framework which must be adhered to in the process of managing medical waste (see table 5).
Table 5. Management of Medical Waste (USAID SAFE 2019) Source of medical waste Activity to manage medical waste management Procurement, storage, Compiled appropriate disposal guidelines for USAID SAFE management, and pharmaceuticals and commodities; disposal of Oriented and provided continuous mentorship to supply chain staff pharmaceuticals on proper storage and disposal of public health commodities Ensured that products were stored according to information 47
provided on the manufacturer’s safety data sheet; Ensured that none of the drugs expired. This helped to prevent the process of disposing off expired drugs. Generation, storage, Supported facilities to put in place adequate procedures and handling and disposal of capacities to properly handle, label, treat, store, transport, and hazardous or highly properly dispose of tested blood, syringes, needles, sharps, and hazardous medical waste other medical waste. Provided onsite technical support to all VMMC providers, family planning providers, and lab personnel in all SAFE supported facilities on medical waste management for hazardous and highly hazardous material. The key impact is that we experienced no severe adverse event neither did we suffer any major infection. Incorporated waste management standards and verification criteria into QA/QI tools and some facilities undertook QI/QA projects in waste management; Conducted site inspections to verify waste management protocol and that waste handling and transportation are orientations were conducted and guidelines are followed; Ensured that boxes for sharps were collected and stored in puncture-proof, impermeable, and tamperproof containers with fitted covers Made clear protocols and responsibilities for onsite collection and storage of waste available Enforced clear color coding of waste bags as follows: o Yellow: Safety boxes for sharps (needles, syringes, blades, broken glass, lancets, scissors, ampoules) o Red: Wet infectious materials (blood, body tissues [foreskins], fluids [discharges)], urine, specimens (stool, sputum, wet dressing, blood bags) o Blue/Black: Non-infectious materials (food, fruits and other food remains) o SAFE plans to re-enforce the QA/QI committees as well as the epidemic and infection control committees at facility level which will ensure that these color-coded bins are present at all time. Ensured that when VMMC occurred through outreach services, incineration of foreskins was done at designated facilities in line with MOH guideline RUTF supplements were imported from South Africa but ensured that aflatoxin analysis was included in the specifications. HEPS was produced locally from Serenje plant. The SAFE management team went to assess production, conditions of the plant i.e. cleanliness, packaging, sealing and storage. The hygiene conditions were excellent. Additionally, the HEPS that the program purchased was freshly produced. The consignment used tricalcium phosphate and their usual HEPS contains Dicalcium phosphate The PlumpyNut was brought from a factory that is UNICEF certified. The MoH used their procedures and processes for importing commodities and aflatoxin test was done and certificate analysis was done and sent prior to dispatching the consignment. The contract 48
stipulated all measures on packaging, storage.
Small-scale rehabilitation In Kabwe, Kitwe and Serenje, supported minor work that generated of health facilities some solid waste from old concrete benches. This waste was stored in big containers with lids and after the work completed, waste was disposed of in a local landfill designated by GRZ
Objective 8: Strengthen M&E Capacity at the Facility, District, and Provincial Levels for Improved Program Management
USAID SAFE continued to effectively collect routine service delivery data from all the supported facilities across all the three SAFE supported provinces. During this reporting period, 412 SIAs and facility staff were trained in SmartCare. As a way of strengthening the use of SmartCare in SAFE-supported facilities, computers and tablets were procured and have then been deployed to the targeted facilities. USAID SAFE continued promoting review meetings in all the SAFE-supported provinces as a platform for providing technical updates to other key stakeholders such as MoH. Routine Data Quality Assessments During this reporting period, USAID SAFE continued conducting the comprehensive Routine Data Quality Assessment (RDQAs) across all supported districts. The primary purpose of this exercise was two-fold: (1) verifying the quality of reported data and (2) assessing the underlying data management and reporting systems for standard program-level output indicators across USAID SAFE-supported sites. The assessment involved conducting physical counts of all records reported in the monthly reports against the SAFE/MoH data source documents. The overall findings from this assessment suggested that data quality is generally good. However, minimal variances (within -/+10%) between what was reported and re-counted on site was observed on some selected indicators. The variances were largely on TX_TB, CXCA_SCRN, PrEP_CURR, and TB_PREV indicators possibly due to inadequate understanding of the indicator definition amongst the SIAs and providers. Based on these findings, onsite orientation was conducted on the areas where these variances were observed, and corrections were made to both the source documents and also the aggregation forms. However, for the gaps that could not be addressed at the time of the RDQA, remedial measures were put in place to address them in the medium-to-long term. Using this comprehensive process of assessing both M&E structures and the quality of data at site level, the M&E system has continued improving over time, supported by continued quarterly technical supportive supervision visits. USAID SAFE will continue using the RDQA processes as an opportunity to identify and address capacity gaps in data collection, data management and adherence to reporting procedures and standards. Orientation of SIAs and facility In-charges in SmartCare 49
To continue strengthening SIA and in-charge capacity to use SmartCare, USAID SAFE worked with Broad Reach to conduct a two-day SmartCare meeting across the three provinces. The orientation focused on six key objectives: 1. To familiarize participants with data entry and reporting functionality of SmartCare 2. To familiarize participants on how to prepare and run reports on the UNAIDS 90- 90-90 indicators 3. To train participants on how to validate aggregate reports in SmartCare 4. To review roles and responsibilities of the Data Associate at facilities to ensure proper and consistent use of SmartCare by their supported facilities. 5. To review the communication channels for sharing data from facility to district and IP reporting channels 6. To orient participants in mentorship strategies
Data review meetings To enhance data use among technical staff, the program continued to hold data review and update meetings across all SAFE-supported districts. The meetings take place at the provincial levels on a quarterly basis with MoH/PHO and provincial donor offices being represented. At the district and facility levels, the forum includes the facility staff, DHOs, and program staff. This platform is used to communicate program focus areas, key performance indicators, technical strategies, and new MOH and program policy directives to participants, including ART clinicians, professional counsellors, SIAs, and health center in-charges whenever they were available.
Together, participants and the Program team members reviewed performance activities and developed action plans on numerous topics including: ● Targeted HIV testing (index testing, PNS, use of screening tools) ● TLD Implementation ● DSD Implementation ● PrEP ● Pediatric/adolescent ART ● EID/eMTCT ● TB/HIV (TB screening, TPT implementation) ● Service integration (ART, FP, NACs, cervical cancer screening) ● VL management (unsuppressed VL management, VL demand creation, sample collection/transportation) ● Strategic information management (retention into care LTFU tracking, TX_CURR trends, data capture tools).
Mentorship and technical support USAID SAFE continued providing technical and mentorship support to facilities on documentation, data collection, data interpretation and more across all supported districts. This was done to ensure that all SIAs and other facility staff have the same understanding of the definition of all KPIs for improved and correct reporting. With continued technical support and mentorship, positive changes have been observed in terms of documentation and reporting. 50
Procurement of Tablets for Data Management USAID SAFE has placed greater emphasis on quality data for decision making, and has therefore continued improving the reporting system by transitioning from paper to electronic data collection using the DHIS2 platform. The developed database is very comprehensive and allows users to report on selected indicators on a daily, weekly, and monthly basis. During the current reporting period, USAID SAFE procured tablets for all facilities to facilitate data capture in real time. Having trained all SIAs in DHIS2 and provided them with tablets, all facilities commenced data entry into the system in July. Migration of historic data from the Access database to DHIS2 will be done in the next reporting period. However, due to changes in PEPFAR MER indicators for COP19, it is expected that some indicators will have to be re- defined. This will be a smooth process due to available TA to support the program. Next steps: Revision of data collection tools USAID SAFE plans to review and revise data collection tools to ensure that they conform and are responsive to the most recent changes in MER 2.4 indicator definitions and High Frequency Reporting requirements (weekly and monthly) data collection tools. Orientation on revised data collection tools will be conducted for SIAs and providers. Implement inter-provincial DQA Scale up to 200 from 190 SmartCare facilities
Objective 9: Strengthen the Public Financial Management Systems of the Ministry of Health and Ministry of Finance to Enable Efficient Use of Direct G2G Funds from USAID
In the quarter under review, public financial management systems strengthening activities in Lusaka, Central, and Copperbelt provinces focused on continued implementation of and adherence to the Risk Mitigation Plans as tools for strengthening public financial management and human resource management systems. These activities work as risk mitigation measures to ensure that the risks identified through the Public Finance Management Risk Assessment Frameworks (PFMRAFs) related to public financial management, capacity development, and budgeting and planning were addressed.
Microsoft Dynamics NAV Implementation
National level At the national level, SAFE was part of the Steering Committee for the National NAV Symposium that took place from 4-5 July 2019 at Cresta Golfview Hotel in Lusaka. The symposium aimed to discuss practical experiences of NAV users from all 10 provinces and to highlight the impediments in the implementation process. It also provided a platform for the MoH Permanent Secretary to reiterate the adoption and use of Microsoft Dynamics NAV as a permanent policy for the Ministry. The NAV Symposium targeted about 105 participants from MoH HQ, partners, all 10 provincial health offices, and selected active NAV users from health institutions in various provinces.
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A post-symposium meeting was held to discuss a number of high-level NAV system management issues resulting from NAV experiences in the process of implementation. The meeting was chaired by the MoH Director Finance and attended by technical participants from SAFE, the USAID Systems for Better Health project (SBH), and MoH HQ. The meeting participants made many progressive decisions on the following NAV implementation subjects: User accounts and passwords Workflows and the business process Budgets and budget revisions Creation and management of master files Technical support or MoH help desk support Financial sustainability Change management and human factor Accountable documents Reports and additional NAV modules
During the quarter, SAFE worked closely with SBH, MoH HQ, and NAV Consultants (SaCIP) on driving the implementation of NAV system from the central level and in the provinces.
Central Provincial Health Office (PHO) SAFE has been working with the Kabwe PHO to ensure the operationalization of the NAV System. In order to ensure that this system is working, SAFE has been providing onsite technical support to finance staff. SAFE ensures that financial transaction batches are posted (uploaded) into the NAV system. SAFE also checks that program officers make requisitions for procurement and payments electronically.
During the quarter under review, tremendous progress was recorded as the KPHO was able to use the NAV system in processing procurements and financial transactions. All the transactions for 2019 are posted on the system, partly through batching and largely through live processing of transactions. Since July 2019, all transactions have been done through the live transactions on the system. SAFE will continue supporting and monitoring the consistent use of the system.
The challenges related to ‘human factors’ still surface at KPHO. Some of the staff are not fully supportive of the system and give various excuses for not using it. High staff attrition also creates a challenge in achieving timely and consistent use. As reported in the previous quarter, the two most senior finance staff (Accountant and Senior Accountant) were both transferred out of the station. However, their replacements are equal to the task and have so far been very supportive of the system. During the quarter under review, the Provincial Health Director (PHD), Dr. Charles Msika, was transferred out of station and replaced by Dr. Kennedy Kabuswe (from Eastern Provincial Health Office). The PHD reported towards the end of quarter. It is expected that he will fully support the use of the NAV system. With this persistent support from SAFE, NAV system consultants, and MoH HQ, usage of the NAV system is expected to reach a sustainable level.
Copperbelt Provincial Health Office During the period under review, SAFE worked with PHO staff to build the NAV system sustainability across the province. The roll out of NAV to all institutions across the province 52 heightened in the reporting quarter. The roll out was administered with onsite mentorship conducted in live processing of accounting and procurement transactions. Onsite mentorship was provided to 18 of the 20 institutions earmarked in this quarter (two tertiary hospitals, four general hospitals, nine district health offices, and three health training schools). All of the institutions mentored are now using NAV, albeit with a number of challenges leading to inconsistency in some institutions. There are some exceptional examples, like Nchanga College of Nursing & Midwifery in Chingola, which have been fully processing all transactions through the NAV system since the day of the onsite support. Additional training was provided to all procurement officers and selected accounting staff in the province in handling the procurement process through the NAV system. This was to build staff capacity in processing procurement transactions and to create procurement related payments (payments to vendors).
In order to address inconsistent use of NAV, SAFE continues to engage and work with the institutions’ management teams to ensure that all manual financial transactions were posted in NAV. SAFE also works to create enough capacity and confidence in all staff to ensure that all transactions are conducted real-time in the electronic system. With this continuous support from SAFE, NAV system consultants, and MoH HQ, SAFE is confident that full system usage in the entire province shall be achieved.
The capturing of accounting transactions using Microsoft NAV Dynamics addresses the risk identified in the risk mitigation plan—lack of an objective way to detect duplicate payments or log and track errors in the manual/excel-based accounting system. The manual system falls short of the acceptable level of authenticity of reports. Continued use of the accounting software will help all health institutions to plan, track, and report on government and donor funds more efficiently and effectively.
MOH New Staff Induction SAFE, working with the PHO HRA staff, facilitated a staff induction training for newly recruited MoH staff in Ndola district. The goal of the induction program was to provide standardized information on the policies, procedures, protocols, and documentation to be followed in the health sector and to familiarize the new recruits on the vision, goals, and organizational structure of the MoH and government in general.
The meeting was officially opened by the Provincial Health Director, who was accompanied by the Provincial Clinical Care Specialist and Provincial Health Specialist. Sixty-five participants (38 registered nurses, three environmental health officers, four lab technologists, and 20 non- medical staff) were oriented in key aspects of their work and related government regulations, including: Vision, mission statement and overall goal of MoH Ethical and professional conduct Conditions of service Financial regulations Staff attitude Training and development Performance management package (APAS) Health information systems 53
Integrated Human Resources Information System (IHRIS) Data Cleaning and Validation in Copperbelt During the quarter under review, USAID SAFE supported the Ndola PHO HRA staff in a data cleaning and validation exercise for records captured in IHRIS. The objectives of this activity were: To confirm the authenticity of the data captured in the IHRIS system by verifying personal identifiers like NRC, employee, MoH, and AE file numbers; To clean duplicate records created in the system as a result of staff movement within the period of data capture by correcting any incorrect position data; To complete data entry for new staff not captured in the IHRIS system; To enter the records of staff trainings not part of the initial exercise conducted earlier in the year.
As of July 2019, MoH Copperbelt Province had an estimated staffing population of 10,153. Of this number, 8,434 (83%) records captured in the system were validated (cleaned), while the balance of 1,719 (17%) were newly captured and validated during this exercise. The majority of the new records included new staff posted to the province either on first appointment or transfer. Due to movement of staff between districts and health facilities, there were duplicate records that required cleaning to ensure only one record exists for each employee.
Post Procurement Supplier Performance Appraisal in Central Province In July 2019, SAFE provided technical support to MoH, Central Provincial Health Office to finalise the G2G 2019 Procurement Planning. This activity involved representatives of all departments and units at the PHO to align all the procurements and activity dates.
After the Procurement Planning, the team conducted an evaluation of the PHO vendors for period July 2018 to June 2019. A total of 57 vendors were evaluated under 10 different categories: stationery; general dealers; cleaning; refreshments; insurance; conference facilities; internet services; motor vehicle spares; drug and pharmaceuticals; and medical equipment. This week-long activity produced a complete USAID G2G Procurement Plan for the PHO and an evaluation report for each supplier.
Earlier, USAID SAFE worked with both Kabwe and Ndola PHO to develop a Supplier Performance Appraisal Tool which was used to conduct the post-procurement supplier performance evaluation.
Asset tracking in Districts in Central Province Working with KPHO Internal Auditors and Administrative Officer, USAID SAFE conducted a follow-up asset verification exercise in 12 Districts Health Offices and two hospitals (Kabwe Central and Kabwe Mine Hospitals) between 25 August to 7 September, 2019.
The objective of this exercise was to check progress in the implementation of recommendations concerning completeness of assets registers, stores records, and general stores management procedures arising from the observed gaps during the earlier visit between April and May 2019 and the subsequent mentorship provided. The follow-up visit showed that 54 some DHOs, including Ngabwe, Chisamba, Mkushi, Itezhi-Tezhi, Shibuyunji, and Kabwe DHO, and the two hospitals recorded improved progress in the implementation of recommendations such as in the use of stores requisitions, supply vouchers, goods inspection certificates, composition of receiving committees, maintenance and completion of consolidated GRZ assets registers, and labeling of assets. For the ones lagging behind, further mentorship was provided to stores and administrative staff as well as lobbying DHDs to support the stores function.
Review of Bank Reconciliation Statements as an Internal Control In the period under review, SAFE reviewed all the bank reconciliations from June to August 2019 at both Kabwe and Ndola PHOs. 100% of the bank reconciliations were correctly done with clear segregation of duties. Cash books were prepared and bank reconciliations were all signed by three different staff (preparer, reviewer, and approver) with names and positions indicated. All outstanding issues were resolved in a timely manner. As of the time of reporting, September 2019 cashbooks were being updated subject to bank reconciliations being conducted by the 15 October 2019.
Regular monitoring by the SAFE PFM team shall continue to ensure consistence and compliance with the standard of segregation of duties as an internal control.
Review of Procurements Conducted Using G2G Funds At Kabwe PHO, SAFE continued supporting the KPHO in the area of procurement planning, procedures, and processes to ensure compliance with public procurement laws and regulations. The areas reviewed included implementation of procurement planning, timely requisitions for procurements, inclusion of terms and conditions, tender evaluations, receipt of goods, and supplier appraisal. Progress in timely procurement requisitioning by Program Officers has been rather slow. Though KPHO only received G2G funds towards the end of the reporting quarter, SAFE had been engaging the Head of Procurement, Senior Accountant, and the Provincial Health Specialist. In doing this, SAFE wanted to ensure Program Officers made procurement requisitions in NAV in time to allow the Procurement Officers do their work in line with procurement procedures and procurement plan. Allocating adequate time for the procurement process allows wide participation of vendors so that the KPHO can realise value for money in their procurements as opposed to rushed procurements.
At Ndola PHO, a review was done for all G2G funded procurements, including those in progress, to monitor actions taken in addressing the risk areas under procurement in the risk mitigation plan. This mitigation addressed implementation of procurement planning, timely requesting, inclusion of terms and conditions, tender evaluations, receipt of goods, and supplier appraisals. The indicator on procurements conducted against the procurement plan was at 100% in the quarter under review, indicating all procurements conducted under the G2G funds were part of the PHO budget and procurement plan.
With the continuous support from SAFE through periodic review and monitoring, both PHOs may sustain the conduct of procurements in line with Public Procurement Act and the procurement regulations, ensuring staff adhere to appropriate procedures and processes.
Annual Performance Appraisal Systems (APAS) A review conducted at KPHO during the quarter indicated that a total of 31 members of staff 55 out of 49 had their Annual Performance Appraisal (APAS) completed, representing a 63% completion rate. KPHO management was engaged to ensure the remaining 18 members of staff were equally appraised as this was long overdue. As for Ndola PHO, 56 out of 61 staff eligible for appraisal (APAS) had their appraisals fully completed. This represented 92% of staff.
Review of Imprest/Advance Retirements and DSA During the quarter under review, PFM SAFE reviewed all imprests and advances paid from the USAID G2G HIV grant. This review also covered payment of DSA to staff attending trainings, workshops, or any out of town meetings. This review is done to verify that imprests are properly retired with relevant documentation (i.e., acquittals sheets for DSAs, fuel receipts, approved memos, budgets, GRZ Form17A, and 44B and a summary trip report). Correctness of DSA was assessed in relation to the staff salary grade, distance from duty station, and whether the staff spent nights out of station. The review indicated that the Ndola PHO paid 100% correct DSAs to staff for the period to end of September 2019.
Training Database In the quarter under review, SAFE engaged the Kabwe and Ndola PHO management on the need to ensure that the training data base was operationalised so that all staff trainings were captured and vetted through the Human Resource Development Officer (HRDO). This helps to root out duplications of trainings for staff and facilities. With the coordination among the program staff in charge of trainings and the HRDO, the development of the training plan, and the operationalization of the training data base, decision-making on development of staff skills as well as the deployment and utilization of such skills would be enhanced and in turn improve staff and institutional performance. With progress being made on the implementation of the IHRIS system, it is hoped that it would provide the required reports on staff training. SAFE has planned to engage with senior Management at MoH HQ to ensure that IHRIS database can provide the required reports on staff trainings in real time. If inadequacies are identified in this area, improvements will have to be proposed to meet expectation.
Cross-Cutting Issues G2G Monthly Review Meeting During the quarter under review, SAFE participated in a G2G monthly review meeting for Ndola PHO and USAID. The meeting was held on 12th September, 2019. The main objectives of the meeting were: To highlight current implementation status; To discuss procurement of medical equipment under cost reimbursement and revised timelines in procurement plan; To discuss early planning for year 3 with projected funding of $2.8m; and To discuss the pending Risk Mitigation plan measures.
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V. Management and Administrative Issues
USAID SAFE continued to maintain well-documented administrative and financial management systems, in line with USAID regulations and JSI Policy to ensure efficient and effective use of Project resources and facilitate compliance, internal controls, financial reporting and overall program management oversight.
During this quarter SAFE continued the recruitment of new positions, replacement of staff who had resigned, and recruitment of more or replacement of ART clinicians, professional counselors, and Strategic Information Assistants. The Program continued to procure items according to PY2 program procurement plan.
USAID SAFE continued its support to facilities by supplying stationery and printed matter, such as SmartCare forms, facility registers…etc. during this quarter.
Administration Lusaka and Provincial Offices All USAID SAFE offices in Lusaka, Kabwe, Ndola, and Solwezi are working efficiently and competently. All new operations staff have been trained and oriented in all operations areas, finance, procurement, fleet management and administration.
During this quarter, SAFE project has received the 20 new vehicles that purchased last quarter, in addition to 8 vehicles disposed and received from “Systems for Better Heath Project” (Abt Associates). Kabwe and Ndola offices continued to be fully decentralized and all new operations staff have been trained and oriented in all operations areas, finance, procurement, fleet management and administration to ensure building capacity and efficiency of the operations staff in all offices.
USAID SAFE continued supporting most facilities in all provinces by procuring stationery, supplies, and toners, as well as photocopying and printing materials such as SmartCare forms, facility registers, training manuals, and handbooks.
Operations team restructure SAFE continued the recruitment of the remaining needed positions according to the operations restructure plan. There are only 2 key position remaining, these are the HR Director and the Procurement Director.
Travel concurrence JSI has obtained USAID concurrence for all international travel thus far per applicable regulations.
Human Resources During this quarter, the Program continued offering fixed-term contracts to some of the consultants (clinicians, SIAs and professional counselors) who had worked for six months with consultancy agreements. 57
The following is the status of USAID SAFE Program personnel at the end of this quarter: Full-time employees: 652 Consultants (with consultancy agreement): 158 Resigned staff: 20 (Clinicians and SIAs)
During this quarter, SAFE has revised its Local Hire Manual in accordance to the new revised labor law, it is expected to roll it out to staff within the next quarter.
Procurement Procurement continued to be a major priority during Q4 as it is the last quarter in the year and the procurement plan for PY2 should be completed. Based on the Program procurement plan for PY2, the following is the current status of the USAID SAFE procurement plan:
PY2 Completed Procurement, either delivered or purchase order has been issued to vendor: 3 glass door commercial refrigerator Sliding door refrigerator Double door refrigerator Lab work tables & Chairs Lab stools Lab Window Blinds Laboratory Plastic transfer pipettes Air conditioning units (12,000 & 18,000 BTU) 5KVA UPS Batteries EPPENDORF pipettes Digital Fridge Thermometers Digital Room Thermometers Blood collection Tubes 5ml & 10ml, holders, needles Voltage stabilizers MUAC Tapes (different sizes) Measuring tapes, Ergonomic circumference measuring (WHR) Stable stadiometer for mobile height measurement Portable adult height measuring board wooden Portable baby/child height measuring board wooden VMMC Supplies MC Kits Health Facility Furniture (Desks, chairs, filing cabinets, benches) Canvas tents Boots, rain coats and umbrellas e-First IT Equipment/supplies for SmartCare Tablets Grippers fro CAP/CTM series Pipette calibrations 58
UPS smart Various medical supplies Smart Cards Card Readers Desktop Mini Tower Computers Laptops RUTF & HEPs procurement 15 ABX micros hematology analyzer Mounted eye wash station Water distiller Ultra Low Freezer Biosafety Cabinets Vitamin B6 – two shipments delivered and the remaining expected in October 2019 HIV Drug Resistance Reagents and Consumables – Expected delivery Oct/Nov 2019 Cobas C111 Chemistry Analyzers with installation & training - Expected delivery Oct/Nov 2019 Sysmex XN Hematology Analyzer - Expected delivery Oct/Nov 2019 ABX Micros Hematology - Expected delivery Oct/Nov 2019
Procurement in Process and anticipated to be completed during the next quarter in PY3: Centrifuge Calibration timers Monsel's Solution (Ferrous Subsulfate) - Requires USAID approval Lateral Wall Retractor LLETZ Biopsy Punch Titanium 10" Pederson LEEP vaginal speculum Large Autoclaving Machine - Requires USAID approval LEEP Machine+Smoke evacuator system + Accessories - Requires USAID approval Thermal Coagulators-Electrical - Requires USAID approval
All the procurement that are in process are anticipated to be completed during PY3 and depending on the funds available.
In Q4 on August 05, 2019, USAID SAFE has received the 20 Hardtop Motor Vehicles, the purchase order has been placed in Q3. The vehicles have been distributed as follows: 10 vehicles for Central province, 5 vehicles for Copperbelt province and 5 vehicles for Northwestern province.
Operations decentralization Currently, Copperbelt and Central provinces offices are fully decentralized in all operations areas: finance, administration, procurement, and fleet. 59
ANNEX A: Progress Summary
Table 1: PMP Indicator progress - USAID Standard Indicators and Program Custom Indicators
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date Number of individuals who received HIV Testing Services 1.1 HTS_TST (HTS) and received their test HTS register 540,975 321,881 313,334 241,469 152,372 1,029,019 190% results, disaggregated by HIV result Number of individuals who 1.2 received HIV Testing Services HTS register 34,518 20,410 19,081 16,405 12,751 68,647 199% HTS_TST_POS (HTS) and received their test results, Positive results Number of individual HIV self- 1.3 HIV_SELF HTS register 96,936 7,367 9,852 13,035 14,609 44,863 46% test kits distributed Percentage of pregnant women with known HIV status at 98% 97% 97% 95% 97% 1.4 antenatal care (includes those ANC register, 111,911 (N) N: 30,612 N: 31,471 N: 28,926 N: 28,028 N: 118,998 97% PMTCT_STAT who already knew their HIV PMTCT register D: 31,200 D: 32,429 D: 29,904 D: 29,352 D: 122,885 status prior to ANC), disaggregated by HIV result HIV-exposed infant registers Number of infants born to HIV- or patient positive women who received a 1.5 PMTCT_EID records, DNA 14,847 2,704 3,905 5,657 6,373 18,639 126% first virologic HIV test (sample PCR or collected) by 12 months of age. POC/near POC log books Exposed infant Percentage of final outcomes follow up/ Baby 1.7 PMTCT_FO among HIV exposed infants mother follow 100% 100% 100% 100% 100% 100% 100% registered in a birth cohort up register/PCR, Patient files, 60
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date SmartCare Number of individuals who have been newly enrolled on Semi-annual 1.8 PrEP_NEW (oral) antiretroviral PrEP to PrEP register 1,732 NA 1,850 NA 5,322 7,172 414% indicator prevent HIV infection in the reporting period Number of adults and children ART registers, 2.1 TX_NEW newly enrolled on antiretroviral 59,902 18,997 17,741 16,261 13,117 66,176 110% SmartCare therapy (ART) Number of adults and children ART registers, 2.2 TX_CURR currently receiving 311,791 220,745 234,883 248,751 270,103 270,103 87% SmartCare antiretroviral therapy (ART) Number of HIV-positive pregnant women who received 2.3 ANC or PMTCT ART to reduce the risk of 14,762 3,212 3,293 3,226 2,996 12,727 86% PMTCT_ART register mother-to-child-transmission (MTCT) during pregnancy Number of HIV positive women in m2m-supported facilities who receive adherence 2.4: CUSTOM and support services (beyond ComCare 3,614 5,210 2,177 7,485 13,193 28,065 777% routine counseling) during their first thousand days of pregnancy to age two Percentage of HIV-positive Cervical cancer 2.6 Semi-annual women on ART screened for screening 65,000 NA 4,529 NA 29,402 33,931 52% CXCA_SCRN: indicator cervical cancer registers Percentage of cervical cancer screen-positive women who are HIV-positive and on ART Cervical cancer Semi-annual 2.7 CXCA_TX: eligible for cryotherapy, screening No Target NA 222 NA 1,131 1,353 indicator thermocoagulation or LEEP registers who received cryotherapy, thermocoagulation or LEEP 61
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date Number of ART patients with Semi-annual 2.8 TX_ML: no clinical contact since their CART Register No Target NA 14,172 NA 14,782 indicator last expected contact Percentage of ART patients with a viral load result 87% 85% 90% documented in the medical 88% 80% N: N: N: record and/or laboratory VL register, 3.2 TX_PVLS N: 273,653 N: 30,166 110,549 122,377 167,971 90% information systems (LIS) Client files D: 310,969 D: 37,787 D: D: D: within the past 12 months with 127,686 143,607 186,424 a suppressed viral load (<1000 copies/ml) Number of health worker full- time equivalents who are working on any HIV-related activities i.e., prevention, Facility HRH This is an 4.1 HRH_CURR treatment and other HIV No Target NA NA NA 2,296 2,296 2,296 records annual target support and are receiving any type of support from PEPFAR at facility and sites, community sites, and at the above-site level Number of PEPFAR-supported facility-based service delivery points supported by your 4.2 EMR_SITE Program reports 245 150 150 157 190 190 78% organization that have an electronic medical record system Number of laboratories and blood centers/banks: A. This is an Engaged in Continuous Quality annual target Improvement (CQI) activities and no data 4.3 LAB_PTCQI Program reports NA NA NA NA 87 87 100% B. Audited and achieved has been accreditation C. Performing an collected HIV-related test and towards it. participating in and passing 62
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date Proficiency Testing (PT) Annual 29 Health Systems INVS_COMD Numb
Number of males circumcised as part of the voluntary medical 5.1 VMMC_CIRC male circumcision (VMMC) for VMMC register 61,190 27,359 13,517 16,942 26,460 84,278 138% HIV prevention Program within the reporting period Number of HIV service delivery points (SDP) at a site Annual 6.1 FPINT_SITE supported by PEPFAR that are Program reports 284 1,072 1,072 377% indicator providing integrated voluntary family planning (FP) services Number of new family planning users identified at HIV service 6.2 CUSTOM delivery points (ART clinics, FP register NA 20,204 18,008 19,889 18,473 76,574 NA ART corners, etc.) within sites supported by PEPFAR Percent of SAFE supported 7.1 CUSTOM sites completing nutrition Program reports 75% (213) 202 202 209 209 209 98% assessments SmartCare, Percent of PLHIV assess for NACS register, 7.2 CUSTOM nutrition resulting in the NA 12% 12% 9% 8% 9% NACS card, ART identification of malnutrition register Distribution SmartCare, of Percent of clients receiving NACS card, food 7.3 CUSTOM 75% 0% 0% 0% 29% 29% 29% supplements nutritional supplements register, NACS was done in register Q4 63
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date Percent of identified SmartCare, malnourished PLHIV 7.4 CUSTOM NACS card, 75% 0% 0% 0% 2% 49 2% rehabilitated to normal NACS register nutrition status. Only 2 Percent of defaulters traced SmartCare, defaulted and 7.5 CUSTOM and referred back to health NACS card, 75% 0% 0% 0% 29% 29% 0% efforts were facility NACS made to trace them NACS Percent of HIV clients that messages 7.6 CUSTOM receive nutrition and HIV Standard Health 75% N/A NA NA 100% 100% 100% integrated in messages/counseling Talk messages health talks Number of clinical staff in USAID SAFE supported 7.7 CUSTOM Training registers 50% (100) 0 30 171 356 557 557% facilities and districts trained on NACs Percent of clinical staff in USAID SAFE supported 7.8 CUSTOM facilities trained in Integrated Training registers 50% 0 0 0 340 340
Management of Acute Malnutrition Percent of facilities with 7.9 CUSTOM Program reports 80% 100% 100% 100% 100% 100% 100% adequate NACS job aids Percent of SAFE supported Program report, 8.1 CUSTOM facilities that are e-First 10% 8% 8% 8% 8% 8% 8% checklist compliant Percent of SAFE supported Minutes, 8.2 CUSTOM facilities that holding DAT 284 110 248 200 183 741 261% Program report meetings Percent of facility in-charges 8.3 CUSTOM Program records NA NA NA NA 100% 100% NA trained in data management 64
Annual Annual Performance Indicator code Indicator definition Data Source Cumulative Q1 Q2 Q3 Q4 % Comment Achieved to target (PY2) Date Percentage of Provincial Risk Mitigation Plan Action Items 9.1 CUSTOM that SAFE is responsible for, Program reports 50% 0% 100% 70% 100% 100% 70% are addressed within the plan year Percentage of bank reconciliations with employee 9.2 CUSTOM Program reports 50% 50% 100% 100% 100% 100% 100% signatures indicating bank statements reviewed Percentage of procurements 9.3 CUSTOM included in the annual Program reports 50% 100% 100% 100% 100% 100% 100% procurement work plan Percentage of MOH provincial employees having received 9.4 CUSTOM Program reports 50% 0% 30% 43% 63% 45% 45% Annual Performance Assessments (APAS) Percentage of MOH employees receiving the correct DSA amount for trainings and 9.5 CUSTOM Program reports 50% 100% 100% 100% 100% 100% 100% meetings paid for through G2G funds. (USAID Program specific) Percent of provincial heath 9.6 CUSTOM office staff trained in record Program reports NA NA NA 86% 90% 90% 86% management Percentage of equipment purchased using G2G funds, 9.7 CUSTOM tagged and tracked using SAFE Program reports NA NA NA NA 100% 100% NA system and included in the correct MOH in asset register
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