SPPHC-HIV Strengthening the Provision of Primary Health Care – HIV Services [IM 17714]

PY6/COP19 Q1 Progress Report October – December, 2019

Submitted Jan 31, 2020

This report is made possible by the generous support of the American people through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID) Cooperative Agreement Number AID-668-A-15-00001. The contents are the responsibilities of the SPPHC project and do not necessarily reflect the views of PEPFAR, USAID or the United States Government. 1

TABLE OF CONTENTS

Table of Contents ...... 2

Acronyms ...... 3

Executive Summary ...... 4

Background ...... 5

COP19 Q1 Results ...... 7 1st 95: Prevention: HTS ...... 7 2nd 95: Treatment Performance ...... 12 3rd 95: Viral Suppression ...... 14

Priority Area Activities ...... 16

Project Management ...... 20 6.1 Coordination and Collaboration ...... 20

Challenges and Next Steps ...... 21

Annex 1: Success Story ...... Error! Bookmark not defined.

Annex 2: Implementation Plan Progress ...... 22

ACRONYMS

AIDS Acquired immune deficiency OGAC Office of the U.S. Global AIDS syndrome Coordinator

ANC Antenatal Care PEPFAR President’s Emergency Plan for AIDS Relief ART Antiretroviral Therapy PHCC Primary Health Care Center ARV Antiretroviral PHCU Primary Health Care Unit BHCs Boma Health Committees PICT Provider Initiated Counseling and CES Central Equatoria State Testing

CHD County Health Department PMTCT Prevention of Mother-to-Child CHW Community Health Worker Transmission

CIP County Implementing Partner PNC Postnatal Care

CMC Camp Management Committee POC Protection of Civilian

DBS Dried Blood Spot PPFP Postpartum Family Planning

DHIS District Health Information System SIAPS Systems for Improved Access to Pharmaceuticals and Services EID Early Infant Diagnosis SPPHC Strengthening Provision of Primary FP Family Planning Health Care HIV Services

FSW Female Sex Worker SSAC South Sudan HIV/AIDS Commission

GRSS Government of the Republic of STI Sexually Transmitted Infection South Sudan TOT Training-Of-Trainers HHP Home Health Promoter TWG Technical Working Groups HEI HIV Exposed Infant UNAIDS The Joint United Nations HIV Human Immunodeficiency Virus Programme on HIV/AIDS

HSSP Health Systems Strengthening USAID United States Agency for Project International Development

HTC HIV Testing and Counseling USG United States Government

IEC Information, Education and VCT Voluntary Counseling and Testing Communication WHO World Health Organization IYCF Infant and Young Child Feeding

MNCH Maternal, Newborn and Child Health

MOH Ministry of Health

MSM Men Who Have Sex with Men

EXECUTIVE SUMMARY 13,160 This quarterly report for the period 1 October to 31st December 2019 received a HIV test highlights the activities, progress and performance of the Jhpiego’s SPPHC project in South Sudan. The Strengthening the Provision of 30% achieved to target Primary Health Care Services for HIV (SPPHC-HIV) project is a 5-year HIV Care and Treatment mechanism, implemented by Jhpiego since 2015. 498 During this period, the project was implemented at 10 Primary Health new HIV cases diagnosed Care Centers across Juba and Tambura including expansion of 20% achieved to target services to two new sites. (Mupoi and Lutheran PHCCs). 4% Yield The project identified 498 new HIV cases from a total of 13,177 previously undiagnosed individuals. This translates to an achievement of 20% of the annual target for people tested positive(HTS_Pos) for 3,938 CoP19 with an overall yield of 4%. The project continued with efforts pregnant women know to scale up efficient and targeted Index testing services at both their HIV status community and facility level. This modality has demonstrated high 37% achieved to target yields when implemented with fidelity.

During this period, SPPHC project prioritized scale of TLD, MMD and 4,558 IPT. With the in country supply chain of TLD90 improving during this PLHIV receiving life-saving period, scale up plans developed in Q4 were implemented with intensity, including weekly tracking using a dashboard, achieving TLD anti-retroviral therapy coverage of 74% and MMD coverage of 95%. Key focus going forward 57% of the target is to ensure more clients are on 6MMD in line with PEPFAR priorities. The partnership with the CSOs NEPWU in Juba and direct engagement of Community Health Workers in Tambura led to a 1,643 significant improvement in efforts to track and return clients with PLHIV with missed appointments and lost to follow up. documented VL results,

In the coming quarter, Jhpiego through the SPPHC will intensify Suppression rate 73% efforts to reduce client losses through client centered care , improving counseling and messaging at ART initiation, scaling up MMD6, strengthening the work of the CSOs/CHWs in tracking clients at community level as well improving the quality of care at site level. TLD 74% coverage MMD 95% coverage

BACKGROUND

South Sudan has a generalized HIV epidemic of 2.5% (2019 UNAIDS Estimates Spectrum). However, of the estimated 186,817 People Living with HIV (PLHIV) in South Sudan, only 45,144 (24%) know their status. Of those, 22,113 are currently receiving ART, of whom, 74% are virally suppressed. Decades of conflict have disrupted critical infrastructure and service delivery, and essential support to South Sudan’s health system is essential for reaching epidemic control.

With funding from USAID/PEPFAR, the Strengthening the Provision of Primary Health Care Services for HIV (SPPHC-HIV) began in 2015 as a PMTCT Option B+ project, and has now expanded to supporting and increasing access to quality, comprehensive HTC, PMTCT and ART services in Jubek and Tambura States. The project supports the continuum of care from HIV testing services to treatment and adherence at 10 health facilities in these regions, leveraging the primary health care system and community health workers in those facilities’ catchment areas to identify PLHIV and link them to life-saving care and treatment.

Goals and Objectives The goal of the project is to support and increase access to quality, comprehensive HIV testing and counseling (HTC), PMTCT, and Antiretroviral Therapy (ART) services – including pediatric and adolescent HIV care – within Jubek and Tambura States. The objectives of the project are:

 Strengthen Western and Central Equatoria States MOH and their County Health Departments (CHDs) capacity to effectively plan, implement, manage and coordinate HIV programs including HTC, PMTCT, and ART services;

 Develop institutional and human resource capacity in comprehensive HIV services; and  Provide quality, integrated, comprehensive HIV services that will reduce new infections and keep HIV- positive patients healthy. Project Coverage The SPPHC project is being implemented in 10 static sites in Jubek State (formerly Central Equatoria State) and Tambura State (formerly Western Equatoria State), with the following services available at each site:

Facility HTS PMTCT EID ART VL TB Gumbo PHCC Yes Yes Yes Yes Yes No Gurei PHCC Yes Yes Yes Yes Yes Yes Juba POC Yes Yes Yes Yes Yes Yes Kator PHCC Yes Yes Yes Yes Yes Yes Lutheran PHCC Yes Yes Yes Yes Yes No Munuki PHCC Yes Yes Yes Yes Yes Yes Mupoi PHCC Yes Yes Yes Yes Yes No Nyakuron PHCC Yes Yes Yes Yes Yes No Source Yubu PHCC Yes Yes Yes Yes Yes Refill Tambura PHCC Yes Yes Yes Yes Yes Yes Total 10 10 10 10 10 5

These static sites are MOH-run Primary Health Care Centers (PHCCs), with the exception of the POC, which is operated by the United Nations Mission in South Sudan (UNMISS) and health services are overseen by International Medical Corps (IMC).

In COP19, the project added 2 static sites Lutheran Church PHCC in Jubek and Mupoi in Tambura states. Additionally, the project operates HIV testing and ART services Kimu PHCC and Aru Juntion PHCU as a satellite sites.

Community Platform

At the community level, the project this year engaged NEPWU as sub awardee, to leverage their community platform for client tracing, with a focus on tracing clients lost to follow up (LTFU) as well as index case partners. In Tambura, the project provides direct support to expert’s client from Twai PLHV association. In POC, the project has directly engaged CHWs to implement LTFU and Index Contact tracing in the community, using Nuer- speaking CHWs to reach that population.

COP19 Q1 RESULTS

1st 95: Prevention: HTS

Facility HTS_TST FY20Q1 % ach FY20 FY20 FY20 % FY20 Target HTS_TST Cum. Cum. Target Yield (%) Cum HTS_POS HTS_POS Ach. Results Target Results Gumbo 181 1293 714% 16 30 188% 2.3% Gurei 9501 1442 15% 326 51 14% 3.2% Juba POC 2364 759 32% 274 20 7% 2.4% Kator 3954 1459 37% 241 84 41% 6.7% Munuki 9866 3177 32% 504 124 25% 4.0% Mupoi - 194 - 297 4 1% 2.1% Nyakuron 6192 1279 21% 291 68 21% 4.7% Source Yubu 1675 812 48% 222 18 8% 2.2% Tambura 8866 2467 28% 324 86 26% 3.4% Lutheran 278 39 13 33% 4.7% TOTAL 42418 13160 31% 2518 498 19% 3.9%

14000 6.0%

12000 5.1% 5.0% 4.7% 4.5% 4.5% 10000 4.3% 4.2% 4.0% 3.8% 3.8% 8000 3.4% 3.0% 6000 2.0% 4000

2000 1.0% 403 458 406 467 375 439 463 506 498 0 0.0% FY18Q1 FY18Q2 FY18Q3 FY18Q4 FY19Q1 FY19Q2 FY19Q3 FY19Q4 FY20 Q1

HTS_Pos HTS_TST Yield

In this quarter, the project has achieved 31% of its testing targets, testing 13,160 individuals, and 19% of its HTS_POS target, identifying from that testing 498 new cases of HIV, for a yield of 3.9%. This yield is above the estimated national prevalence of 2.2%, and varies across sites, with yields ranging from 6.7% to 2.2%. Over time, yield has stayed within a fairly consistent range of 3.4 – 5.1%; however, over the last two quarters, the absolute number of new cases identified has been at around 500. Performance is largely driven from achievement at high volume sites facilities, with Kator in particular achieving 41% of its positivity target. This quarter, significant improvements in case identification in Tambura have led to an over-achievement against target.

Case Identification by Facility

Tambura Kator 7% 100 7% 120 9% 10% 8% 6% 7% 80 100 7% 7% 7% 8% 5% 4% 3% 3% 80 60 3% 4% 6% 3% 3% 4% 4% 2% 60 4% 40 2% 3% 4% 2% 40 20 1% 20 2% 0 0% 0 0%

HTS_POS Yield HTS_POS Yield

Munuki Nyakuron 7% 180 7% 80 5% 6% 6% 6% 160 70 5% 5% 5% 5% 5% 6% 4% 5% 140 4% 60 4% 4% 5% 4% 120 50 3% 3% 4% 4% 100 40 3% 2% 3% 80 3% 30 60 2% 2% 40 20 1% 20 1% 10 0 0% 0 0%

HTS_POS Yield HTS_POS Yield

Gurei Source Yubu

70 7% 25 7% 7% 7% 60 6% 6% 20 5% 50 5% 5% 4% 4% 15 4% 4% 40 4% 4% 4% 4% 3% 3% 30 3% 3% 3% 3% 10 3% 2% 2%2% 20 2% 2% 5 1% 10 1% 1% 0 0% 0 0%

HTS_POS Yield HTS_POS Yield

POC Gumbo 60 7% 35 8% 6% 6% 6% 30 7% 7% 50 6% 6% 5% 5% 5% 25 6% 40 5% 5% 5% 4% 20 30 4% 4% 4% 3% 3% 15 20 2% 3% 2% 10 2%2% 2% 2% 10 1% 5 1% 1% 1% 0 0% 0 0%

HTS_POS Yield HTS_POS Yield

FY20 HIV Positive Case Volume and Positivity by Modality 200 25% 180 172 21% 160 146 20% 140 120 15% 100 91 80 10% 63 60 8% 6% 42 40 5% 4% 20 3% 3% 9 12 2% 0 1 2% 0 0 0% 0% 0%

Performance by modality performance as expected index and TB with highest yield of 21% and TB 8%. The testing data by modality gives some explanation for testing, with PMTCT (PMTCT ANC1 and post ANC1) accounting for 33% of overall HTS_TST at yield of 3% and 2 % respectively. Other PITC has a lower-than-average yield, although it accounts for around 35% of all new positives.

Index Testing

Acceptancy rate 73% 600 Yield 21% Link 98% 500

400 old client, 21 Children, 104 146 300 486 old client, 21 Known positives, 41 200 New Pos, 42 New clients, 326 Partner, 287 100 New clients, 233 New Neg, 162 41 0 HTS_POS # index offered # acceptedthe # contacts elicited # of contacts Initiated on ART services index services tested

Continuing the trend from COP18, the SPPHC project has continued to scale Index testing as the most effective, and highest-yield modality. Efforts at community index testing, new this quarter, are described in the implementation section below. In addition, there has been a renewed focus on fidelity of testing at the facility level, and as a result, the project has been successful in predominately identifying sexual partners – rather than children – as the contacts elicited from Index patients: of those contacts tested, 50% were sexual partners, giving a yield of 35%.

PMTCT and EID

FY20 PMTCT_STAT FY20 PMTCT_STAT. FY20 PMTCT_STAT Facility Target Results ach. (%)

Gumbo - 315 - Gurei 3033 798 26% Juba POC 436 373 86% Kator 954 287 30% Lutheran - 97 - Munuki 2700 1062 39% Nyakuron 2124 460 22% Source Yubu 270 106 39% Tambura 1156 213 18% Total 10673 3711 35%

PMTCT_STAT Coverage (93%) 120% 100% 100% 100% 97% 100% 90% 94% 90% 91% 92%

80%

60%

40%

20%

0% Gumbo Gurei Juba POC Kator Lutheran Munuki Nyakuron Source Tambura Yubu

Of 3883 Pregnant women who visited a project-supported facility for ANC-1, 3866 know their HIV status – a coverage of 99.5%, and a project achievement of 36%, The coverage has been notable in 3 facilities at 100% PMTCT_STAT. Munuki, Gumbo and Nyakuron, shows low coverage of 90% noted that PMTCT as point of standard care expected 100%. From that testing, 113 positive women were identified, and 106 (PMTCT_ART) new and known positives began treatment during the reporting period, for a PMTCT linkage of 94%. 7 clients declined treatment and have been followed up by the provider.

FY20 Q1 EID Results by Age Groups 80 70 60 21 50 40 30 9 12 47 7 20 2 10 23 21 24 2 0 2 2 Specimen collected Results received Positive Negative Results pending Positive HEI started ART

<2 months 2-12 months

There has been substantial improvement in PMTCT_EID performance compared to previous COP in terms of rapid case identification. 69% of infants tested were tested at under 2 months; 100% of all new HEI were initiated on ART. This success has come through improved efforts at tracking of mothers through delivery plans and engagement of CSO (NEPWU) mentor mother pairs to PMTCT mothers, described in the activity section below. From the PMTCT clinic, 68 infants had a virologic HIV test within 12 months (PMTCT_EID), representing 23% of the project’s COP19 target. From these tested 2 HIV-exposed infants were diagnosed positive (PMTCT_HEI_POS), all of whom were immediately initiated on ART.

TB/HIV

FY20 TB_STAT FY 20 % FY20 TB_STAT TB cases Facility TB_STAT Coverage TB_STAT Target Ach. Registered (A) Cum. (B) (%) (B/A) Target (D) (B/D)

Gurei 51 51 100% 20 255% Juba POC 57 51 89% - - Kator 489 460 94% 2808 16% Munuki 542 512 94% 4072 13% Tambura 31 31 100% 112 24% Total 1170 1105 94% 7012 16%

HIV care and treatment integration at TB services has continued in five SPPHC supported sites in Jubek and Tambura this quarter: of the 1170 clients enrolled on TB treatment in project-supported facilities, 1105 had a HIV test (TB_STAT), giving a TB coverage of 94% - an improvement from the previous COP result of 85% coverage. Despite this improved coverage, performance to target remains low, with a 16% TB_STAT achievement this quarter – with the bulk of the target numbers coming from Munuk. Of those who know their status, 93 are HIV positive (new and known) and 100% were initiated on ART (TB_ART).

2nd 95: Treatment Performance

Quarterly Proxy Trends in Linkage to Treatment 600 140%

114.6% 112.1% 120% 500 105.8% 102.2% 105.3% 104% 103% 105% 92.4% 100% 400

80% 300 60%

200 40%

100 20%

0 0% FY18 Q1 FY18 Q2 FY18 Q3 FY18 Q4 FY19 Q1 FY19 Q2 FY19 Q3 FY19 Q4 FY20 Q1

HTS_TST_POS TX_NEW Proxy Liinkage

Facility TX_NEW COP19 Target COP19 Q1 Result Achieved % Gumbo 22 30 136% Gurei 385 57 15% Juba POC 2 20 1000% Kator 398 118 30% Lutheran 29 13 45% Munuki 525 126 24% Mupoi 53 3 6% Nyakuron 309 59 19% Source Yubu 301 18 6% Tambura 492 83 17% Total 2516 527 21%

In this quarter, 527 PLHIV were newly initiated on life-saving ART, for a 21% achievement to target. This represents a 105% proxy linkage – indicating that lower performance-to-target on TX_NEW is driven by similar trends in case identification. The >100% linkage arises from several facilities receiving referral from the E2A Key Populations project - specifically Kator (140% linkage) and Gurei (123%) – where 64 Key population were referred to the project for care and treatment. Cohort linkage is at 87%, below the target of 90% linkage, despite efforts of facility-based CHWs to physically link new cases to immediate treatment.

TX_CURR results by facility 1600 120%

1400 102% 100% 100% 94% 1200 80% 1000

62% 800 59% 60% 54% 600 44% 43% 40% 400 20% 200 17% 15%

0 0% Gumbo Gurei Juba POC Kator Lutheran Munuki Mupoi Nyakuron Source Tambura Yubu

TX_CURR FY20 Q1 % achieved

This quarter, 4459 clients were actively receiving ART from the 10 SPPHC supported facilities in Central and Western Equatoria states. This represents 57% of the COP target. 58% (2651/4559) were female and 5% (207/4559) were children.

As in previous quarters, retention has been the critical issue for the project this quarter: despite a Q1 TX_NEW of 527, the quarter-on-quarter TX_NET_NEW from Q4 TX_CURR was 426, meaning the project lost 101 clients this quarter.

% # Clients APR APR Unexplained Unexplained Returned TX_CURR TX_CURR TX_NEW TX_NET_NEW Client Loss or Client Loss or to Name of FY19 Q4 FY20 Q1 FY20Q1 FY19Q4 D=(B- Gain FY19Q4 Gain FY19Q4 Treatment Facility (A) (B) (C) A) E=(D-C) F=(E/(A+C)) in FY19Q4 Gumbo 52 65 30 13 -17 -21% 7 Gurei 434 433 57 -1 -58 -12% 17 Juba POC 102 130 20 28 8 7% 7 Lutheran 13 13 13 0 0% 2 Kator 676 769 118 93 -25 -3% 76 Munuki 812 719 126 -93 -219 -23% 33 Mupoi - 43 3 - - - 0 Nyakuron 412 452 59 40 -19 -4% 50 Source Yubu 338 452 18 114 96 27% 26 Tambura 1307 1483 83 176 93 7% 82 Total 4133 4559 527 426 -101 -2% 300

To address the retention issue, the project has implemented a number of strategies. These have included t TX_CURR data quality reviews and improvements in data entry and aggregation; engaging CSOs to trace defaulters, return them to care and treatment, and document reasons for low adherence; scale-up of MMD – with 95% of eligible clients currently receiving more than 3 months’ ART – and rollout of TLD, which is documented in the implementation section below. Despite these efforts, adherence continues to be a challenge, and while the project has seen some successes in returning defaulting clients back on care and treatment, work remains to be done to prevent treatment default in the first instance.

3rd 95: Viral Suppression

4000 3625 3500 Suppression rate in Females , 73% VL coverage 71% and in Males 67% 3000 2562 2500

2000 1839

1500

1000

500

0 TX_CURR FY19Q3 TX_PVLS(D) FY20 Q1 TX_PVLS(N) FY20 Q1

600 90%

80% 77% 78% 77% 500 75% 74% 75% 72% 70% 70%

400 60%

50% 300 40%

200 30%

21% 20% 18% 100 11% 10%

0 0% 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+

Result received <1000 copies Suppresion rate

Viral Load testing services are provided in 8 of the 10 project-supported facilities, with the other two, newer facilities currently awaiting the results of a readiness assessment, conducted in collaboration with AMREF, before implementing VL services. This quarter, 2562 individuals had a VL result documented (TX_PVLS (D)), giving a coverage of 71% against the 6 months’ prior TX_CURR. Of those 2562, 72% had an undetectable viral load result. This represents a 58% achievement to target for TX_PVLS (N), with all sites showing a strong performance for the expected quarterly achievement.

TX_PVLS (N) Facility COP19 Target COP19 Result % Gumbo Gurei 790 268 43% Juba POC - 14 Lutheran - Kator 814 235 40% Munuki 955 291 35% Mupoi - - Nyakuron - 219 - Source Yubu - 94 - Tambura 1852 718 48% Total 4411 1839 58%

PRIORITY AREA ACTIVITIES

The above results were achieved through the implementation of the activities detailed in the approved workplan, and through adaptive response to facility-specific contexts in the course of Q1. A detailed implementation plan detailing the status of each activity in the COP19 approved workplan is attached as an Annex to this report. However, some key programmatic achievements responding to PEPFAR Priority Areas are highlighted below.

Priority Area 1: Scale up Index Testing with a focus on reaching males

Community Index Testing This quarter, in addition to routine facility-based index testing services, the project leveraged its community platform to conduct Community Index Testing in high-volume sites (Munuki, Nyakuron, Gurei, Kator, and Tambura). Through its Juba-based CSO, NEPWU, as well as directly though contracted CHWs in Tambura and at Juba POC, CHWs trace clients identified as contacts from Index patients, and perform community-based testing. This strategy removes an important barrier to care – reluctance to come to a facility for services – and has led greater case identification among contacts of index patients this quarter.

Data for decision-making Using WhatsApp groups and reporting tools at the community level, we quickly realized that the first two weeks of community index testing were resulting in large numbers of children and low case identification. As a result, we moved quickly to re-orient our CHWs to focus on adults, and only test children when the mother is HIV+. As a result, over 70% of our INDEX_POS result this quarter was among sexual partners, who as a group had a yield of 45%.

Priority Area 2: EID: Increasing the proportion of HEI tested before 2 months of age Implementing a Surge Plan At the start of this quarter, Jhpiego undertook a simple Human Centered-Design activity, and traced the client journey for PMTCT VL patients, to better understand the low VL coverage among this cohort. We identified a major barrier – in facilities with both an ART and PMTCT space, clients who were receiving treatment through PMTCT spaces were required to receive VL testing through the ART site. This introduce an additional, unnecessary step for PLHIV to receive PMTCT VL and EID testing. In mid-Q1, we removed that step.

Data for decision-making Then, out of the PMTCT site, we implemented a surge plan: going back to registers and systematically identifying mother-infant pairs. We then used the registers to identify the due dates of expectant mothers. We then start preparing the expectant mother, advocating for delivery at the same facility where they receive ART. Regardless of delivery site, the mother is given Nevirapine for the newborn after delivery. Then, after delivery, facility-based providers – with support for mentor mothers – follow-up at birth, and conducted EID testing as soon as possible at the facility. As a result, 69% of the children tested for HIV received a test at below 2 months – a marked improvement on previous quarters.

Priority Area 3: Retention in Care and achieving Viral Suppression Improving LTFU Documentation To better improve the quality of documentation of LTFU – and to better understand who was getting lost and why – this quarter, Jhpiego developed and piloted a new ‘Missed Appointment and LTFU Register’. This register was subsequently printed and delivered to each of the 10 static sites, and includes fields for standardizing data collection around LTFU tracing effort results.

Data for decision-making Data from this tool is then collected and entered into a weekly LTFU dashboard, shared with facilities, and used to identify quick corrective actions at each static site. As a result, we have been able to get a better picture at the facility level of trends among LTFU, and our facilities and communities are better equipped to trace those LTFU through our programmed activities. The tool is also improving the quality of the data we collect – combined with mentorship from our MER team, we are working to improve the documentation of physical land marks and contact details of client, to address the underlying issues in cases where the outcome is “unable locate”.

Understanding Reasons for LTFU As part of the expanded scope of our CHWs and CSO partners, all clients returning to care and treatment at project-supported sites after defaulting are 29% interviewed briefly, to ascertain reasons for default. This data is then aggregated to better understand 46% the underlying reasons for LTFU in order to appropriately respond. For example, we learnt this quarter that temporary travel (e.g. to visit relatives, 10% for seasonal work) was the single most frequent 9% reason for LTFU. Knowing this, we are able to guide 6% providers and ensure clients travelling are counselled – and provided enough treatment for them to remain healthy. 1 2 3 4 5

Building the Capacity of Community Actors Additionally, this quarter, we are continuing the community tracing efforts led by CHWs and CSOs first implemented in COP18, as an effective method for LTFU tracing, working hand-in-hand with clinicians to trace those who miss appointments. In Q1, we held an annual review meeting to review performance, discuss challenges, and jointly develop solutions with these community experts.

We also have tweaked our community LTFU strategy in areas where NEPWU do not operate: in Juba POC, where NEPWU have encountered access issues, we have directly engaged with 4 CHWs from the Nuer community living in the POC. In Tambura, where our COP18 CSO had major performance issues, we are directly working with CHWs, and have seen a marked improvement in performance.

Priority Area 4: Finding men: Plans and strategies that "work" in addressing challenges Institution-Based Testing In Tambura, in order to improve the proportion of men – many of whom are not willing to come to the facility level to receive HIV testing and counselling – Jhpiego staff conduct community-based risk screening and HIV testing at select institutions where men are well- or over-represented, such as in local government and industry. Of those tested at the community as a whole, 46% were men – much closer to gender parity than in some other OPD modalities. This community-based testing resulted in a yield of 4% and 29 new positives identified. Despite the success, work remains to be done on more rigorous screening, greater targeting of men, and ensuring that linkage is complete for any newly-identified cases.

Differentiated Service-Delivery (DSD) and Community Index The main DSD strategy of MMD has been rolled out and implemented across all sites (see below). Additionally, community index has also led to successes in reaching men (see above). Other models, such as dedicated youth- friendly hours and spaces, and Community ART Groups, have not been conducted this quarter, but are a priority for implementation in Q2.

Priority Area 5: Scale up of TPT

250 All facilities received IHN

200

150

100

0 Jul_19 Aug_19 Sept__19 Oct_19 Nov_19 Dec_19 Jan_20 IPT Roll-out Efforts Results from our TPT efforts are described in the results section above. From an implementation view-point, we have been able to see a marked improvement in our performance as a result of our advocacy at above-site levels – the positive trend in performance has occurred in late December, at the time when all facilities received INH. Through frequent data monitoring and on-site mentorship, we have been able to increase safe access to IPT, and to date, no adverse events have been reported.

Priority Area 6: Viral Load: Plans and strategies to improve viral load coverage

See results discussion above.

Priority Area 7: TLD Transition and MMD:

TLD Transition 5000 Building on the success of COP18 Q4, 4500 the project has continued to aggressively scale its TLD distribution 4000 1214 1264 3500 efforts. From a 56% coverage in 1866 October of 2019, by the end of 3000 1992 December, 74% of eligible clients 2500 were successfully transitioned to TLD 20003823 3424 (see Figure X, right). The transition 1500 3058 3302 strategy has revolved around facility- 2141 2427 based scale-up plans; training and 1000 orientation – and ownership – to 500 facility-based providers on SOPs, 0 8 254 adverse event monitoring tools, and 1 2 3 4 5 6 job aids. Series1 Series2 Data for decision-making Above all the strategy has focused on data. The project developed site-specific targets and timelines to ensure key benchmarks for transition were being met. A TLD dashboard was developed with facility-level data to closely monitor stocks, avoid stock-out, and review progress. And routine meetings with providers to discuss the developed scale-up plan and agree method of monitoring the progress on weekly basis

Multi-Month Dispensing Clients on 3+ MMD by Week MMD is a game-changer for adherence among 4500 clients on treatment. Using the TLD transition as an opportunity to redouble efforts – as well as to 4000 integrate data use in facility-level programming – 3500 the project used similar tools to the TLD transition (dashboards, weekly targets, regular meetings to 3000 review benchmarks). By the end of Q1, the project had achieved coverage of 3+ months’ MMD across 2500 all implementation sites.

2000 The challenge now remains in transitioning to 6 months. As of the end of Q1, only 6% of clients 1500 were receiving 6 months of treatment, due to 1000 commodity and policy issues at the national level. However, we anticipate this to be resolved through 500 advocacy at the TWG level and through PEPFAR communication channels, and are poised to 0 proceed with scaling up 6 months MMD to facilities.

PROJECT MANAGEMENT

6.1 Coordination and Collaboration

Coordination with USAID To enhance project performance monitoring and timely decision making, Jhpiego this quarter has participated in regular weekly coordination meetings with USAID/PEPFAR, submitting weekly dashboards to review key indicators and track facility-level performance. These meetings have provided a platform for detailed data review and timely raising of issues. Jhpiego has also participated in PEPFAR TWG meetings, where we have been able to share feedback on areas of concern, such as commodity issues and MMD.

Coordination with Other Partners As USAID’s Care and Treatment partner in South Sudan, the project has close working relationships with the following USAID/PEPFAR Implementing Partners (IPs)/projects and non-PEPFAR NGOs:

Partner Coordination Intrahealth Key Populations identified by the Evidence to Action (E2A) project, are referred to a number of International SPPHC static sites to receive HIV services (ART, VL testing). We will continue to partner with IHI to ensure person-centered services are provided to KPs Amref VL/EID sample testing for all PEPFAR Implementing Partners is managed by Amref under their CDC- funded Labs project. This year, we have coordinated closely with Amref through regular meetings and data sharing on turnaround times International In POC1 and 3, IMC is the humanitarian partner operating the POC health care clinic, acting as a Medical Corps host to SPPHC services and activities. As such, the project works closely with IMC to coordinate activities and referrals to/from OPD services operated by IMC.

CHALLENGES AND NEXT STEPS

A review of the above data highlights a number of critical priorities for the Project in the remainder of the year to ensure it reaches its targets. In particular, we have identified the following challenges as key to the success of this project:

Challenge Strategies Retention remains the number  Scale up MMD, emphasizing 6 months as the standard that must be one challenge for the project implemented moving forward  Continue to CSOs, CHWs to conduct defaulter tracing  Support use of clinical tools (appointment books, algorithms and SOPs) and effective counselling  Ensure client records and aggregate data are accurate  Establish Community ART groups, as per the workplan Men continue to be under-  Ensure that high-volume modalities continue to be emphasized, in represented in HIV testing particular, Index Testing for partners results  Work with facilities to extend hours, provide dedicated spaces for men in COP19 – this will be prioritized in Q2. 

ANNEX 1: IMPLEMENTATION PLAN PROGRESS

# Activity Status Notes Jhpiego has used TWG meetings to participate Participate in monthly HIV TWG meetings and contribute to policies, guidelines, 1.1.1 Ongoing in discussion about TLD transition and IPT, reporting tools development among other critical issues Due to lack of other financial support to Participate in quarterly State-level HIV coordination meetings to review critical issues, 1.2.1 Not Started SMOH, these meetings are no longer collaborate on problem-solving, and develop joint action plans to develop capacity occurring 1 joint visit to Gurei took place with the MOH, 1.2.2 Conduct quarterly joint supportive supervision visits Ongoing focusing on stock and commodity issues Implement monthly stock-taking, support above-site forecasting efforts, and attend 1.2.3 coordination calls with IPs and national warehouse to prevent stock-outs of key Ongoing commodities including TLD and TPT Collect, analyze, and share VL sampling turnaround times with Amref, USAID and other 1.2.4 Not Started Not started – Amref collecting their own data key stakeholders Share preliminary findings on service-delivery innovations, models, and activities that 1.2.5 have been successful in reaching men, AGYW, and other key demographics, through Not Started TWG, meetings, and other fora To be completed in Q2; SIMS tools being used 2.1.1.1 Update supportive supervision tools Late to highlight facility expectations in critical issues 2.1.1.2 Conduct monthly supportive supervision Ongoing Ongoing at all sites 2.1.1.3 Conduct weekly mentorship (reported quarterly) Ongoing Ongoing at all sites 2.1.2.1 Conduct three 2-day refresher training for 20 ART and PMTCT providers Late To be conducted in Q2 Postponed/will be reevaluated in Q2, given 2.1.2.2 Conduct two 2-day refresher training for 21 HIV counselors (Juba 15 and Tambura 6) Not Started renewed focus on LTFU tracing over case identification 2.1.3.1 Distribute updated and revised SOPS and job aids Ongoing 2.1.4.1 Participate in TWG meetings Ongoing Specifically: IPT, missed appointment and Updated tools and registers are distributed to all facilities; all 32 providers oriented on 2.1.4.2 Ongoing LTFU register, EAC flipcharts (for children, the new tools Adult and Adolescence), index register 2.1.5.1 1000 Flipcharts, leaflets, pamphlets developed and distributed Late Not started 2.1.5.2 1500 index and partner notification leaflets developed and distributed Late Not started

# Activity Status Notes Materials developed by USAID were 2.1.6.1 Develop screening and referral toolkits for IPV Complete distributed to facilities 2.1.6.2 Orient providers on IPV screening and referral materials Late Conduct site-level assessment through microplans and SSV on gender-responsive 2.1.6.3 Late programing, including gender & age of providers and CHWs, hours / days of operation Rapidly scale up identified site-level strategies to address gender-related service delivery 2.1.6.4 Not Started gaps, including DSD models and dedicated hours for men, AGYW, on a site level Evaluate effectiveness of gender-sensitive interventions and adjust based on further 2.1.6.5 Not Started evidence Partnering with Intrahealth, provide KP-friendly services training for providers at 2.1.6.6 Not Started Munuki, Kator, Nyakuron, Gurei and Gumbo PHCCs 2.1.7.1 Conduct a rapid HIV service availability and readiness assessment of two private clinic Complete 2.1.7.2 Develop workplans with private clinics aligned with HIV service delivery standards Late Hold OJT training and mentorship on adherence to standards including recording and 2.1.7.3 Late reporting Weekly private clinic visits by HIV Technical Advisor and member of M&E team for first 3 2.1.7.4 Late months after service delivery initiated and bi-monthly for remainder of the financial year 2.2.1.1 Develop updated community sensitization package Late 2.2.1.2 2 community sensitization conducted for a total of 50 CHWs (Juba and Tambura) Not Started 2.2.2.1 Conduct client mapping exercise Late Mapping begun but not finalized 2.2.2.2 Data collection tools and SOPs developed for community ART groups Late 2.3.2.3 Establish 30 Community ART groups and Refill Late 2.3.2.4 Training conducted for 30 retention groups leaders Not Started The SPPHC added Lutheran Church and Mupoi Expand PITC to 2 new static sites and 4 new satellite sites (St. Kitizo PHCC, Rock City and new static sites and Rock City is satellite 3.1.1.1 PHCC, plus 2 private sector sites) recruiting and orienting new staff and providing Ongoing site and all tools, registers and SOPS were registers, SOPs, and tools to new sites provided. 3 new satellite sites are being identified 3.1.1.2 Provide 5 staff at outreach sites with monthly airtime incentives Ongoing 3.1.1.3 Extend working hours including weekends at select sites (Munuki, Tambura, Kator) Not Started Not started 3.1.1.4 Providers perform PITC Ongoing Index clients identified, documented in the index register /Contacts elicitation form and 3.1.2.1 Ongoing followed-up 3.1.2.2 Support client disclosure, contact elicitation and partner notifications Ongoing 3.1.2.3 Ongoing 3.1.2.4 Trained counselors conduct community index testing Ongoing

# Activity Status Notes Sensitize OPD clinicians to refer TB presumptive for HIV testing in Q1 and provide 3.1.3.1 Ongoing monthly supportive supervision throughout rest of PY Use facility based patient navigators to link TB clients to HIV testing, as part of their 3.1.3.2 Ongoing routine OPD navigation 3.1.3.3 PITC for TB patients Ongoing 3.1.4.1 Develop HTS quality checklist Late 3.1.4.2 Conduct regular internal HTS QA as part of mentorship Not Started 3.1.4.3 Conduct EQA activities Not Started 3.2.1.1 Provide PITC during dedicated youth-friendly hours Not Started 3.2.1.2 Sensitize providers at new sites on integration of FP services into routine PMTCT and HTS Late New sites don't have FP services 3.2.2.1 Coordinate with IHI on continuous referral mechanism for Key Populations Late The KPs connected by IHI but we don't 3.2.2.2 KP-friendly PITC at Munuki, Kator, Nyakuron, Gurei and Gumbo PHCCs Ongoing provide PITC Facility level coordination meetings with 4Children on OVC –HIV bi-directional s referral 3.2.3.1 Ongoing mechanism 3.2.3.2 Provide HIV testing for all children referred from OVCs Not Started Pending 4Children referrals 3.2.3.3 Refer OVCs identified through routine service delivery to 4Children Ongoing 3.2.4.1 Implement solutions identified in Activity 2.1.6.4 on a site-by-site basis Not Started Ongoing. Pregnanat mothers who come for ANC1 visit must be tested for HIV and the 3.3.1.1 PMTCT providers test ANC patients during ANC1 visits In Progress HIV+ mothers are being initiated on ART immediately after testing except the known positives . 3.3.1.2 PMTCT providers initiate HIV+ mothers on ART Ongoing Establish and maintain mother-to-mother peer support groups to help with adherence 3.3.1.3 Ongoing counseling, appointment notification/follow- up and tracking clients 3.3.2.1 PMTCT providers perform routine EID Ongoing 3.3.2.2 CHWs track all HIV positive mothers and HEI pairs on weekly basis Ongoing 3.3.2.3 Provide transportation support for mothers to bring HEI within 4 weeks of birth Late Note done in Q1 3.4.1.1 ART Providers initiate newly-identified positive clients on ART Ongoing 3.4.1.2 Transition clients on to TLD based regimen Ongoing 3.4.1.3 Conduct patient file review for MMD eligibility Ongoing 3.4.1.4 Ongoing ART service delivery for all clients Ongoing 3.4.2.1 Provide VL testing for all eligible clients Ongoing 3.4.2.2 Update HVL electronic register for all facilities Ongoing 3.4.2.3 Conduct EAC for all HVL Clients; provide repeat VL after 3 EAC sessions Ongoing

# Activity Status Notes 3.4.2.4 Sensitization of counselors on VL and EAC Ongoing 3.4.3.1 Screen all ART clients for symptoms of TB Ongoing 3.4.3.2 Scale-up TPT at supported sites according to INH availability Ongoing 3.4.4.1 Provide MMD to all eligible clients Ongoing ART providers/Data Clerks update Appointment logs daily. Ongoing 3.4.4.2 ART providers /DC proactively contacts clients prior to scheduled appointments. Ongoing 3.4.4.3 Provide airtime to ART providers, CHWs, CSOs for tracing LFTU clients Ongoing 3.4.4.4 Use of community ART groups and LTFU tracing efforts Late CHWs routinely support PLHIV through phone calls and home visits with support from 3.5.1.1 Ongoing facility clinicians 3.5.2.1 CHWs and CSOs perform community index testing Ongoing 3.5.3.1 Established community ART groups and provide treatment at community level Late Conduct regular supportive supervision, OJT, mentorship on data capture, reporting, and 4.1.1.1 Ongoing tools used e.g. registers 4.1.1.2 Generate weekly dashboards by facility to inform decision making Ongoing Ongoing data review meetings with the 4.1.1.3 Conduct monthly data review meeting for facilities In Progress facility staff Quarterly DQAs, to ensure accuracy and completeness of data, and identify priorities for 4.1.1.4 Not Started intervention 4.1.2.1 Use WhatsApp group for daily activity monitoring across facilities Ongoing 4.1.2.2 Establish and implement DHIS2 instance for site-level aggregate data Late Planned for Q2 4.1.2.3 Train M&E team on database management Not Started Planned for Q2 4.1.2.4 Develop and refine SOPs for data management and security Not Started Not started 4.1.2.5 Develop environmental management and mitigation plan Complete 4.1.3.1 Develop project documentation plan Not Started Not started 4.1.3.2 Develop and submit abstracts to 2 international conferences Not Started Planned for Q2 4.1.3.3 Develop one manuscript for submission to a peer review journal Not Started Planned for Q2 4.1.3.4 Develop quarterly success stories Ongoing