COP18 Zimbabwe PEPFAR Funding – COP18 Period: 1 October 2018 to 30 September 2019 Total Funding: $145,541,203 • testing, treatment (including drugs), DREAMS, prevention, laboratory, strategic information, HIV/TB, systems strengthening • VMMC: $32,384,807 • OVC: $17,838,563 COP17 to COP18 – Reach 90% ART Coverage in all sub-populations 3 How the picture has changed in 10 years 2008 2018 4 A population level perspective of the HIV epidemic 5 2 years post-ZIMPHIA data collection: ZIMPHIA Where we stand NOW with progress towards epidemic control Males 100% 78% 76% 73% 75% 62% 66% 53% 65% 57% 50% 25% 0% <15 15-24 25-49 50+ Total PLHIV Known Status On ART VLS Females 94% 100% 85% 85% 80% 72% 75% 75% 58% 65% 50% 25% 0% <15 15-24 25-49 50+ Total PLHIV Known Status On ART VLS 6 Geographic ART coverage by end FY18, with absolute number of PLHIV left to find 7 2017 ART Coverage & Absolute Treatment Number Gap Total Gap Total Abs District PLHIV All Ages F 15-19 M 15-19 F 20-24 M 20-24 F-25-29 M 25-29 F 30-49 M 30-49 F 50+ M 50+ (All Ages Number & Sexes) (All Ages & Sexes) 01 National 1,315,900 92% 86% 98% 71% 89% 88% 84% 70% 75% 66% 85% 201,302 Harare 222,000 76% 98% 83% 66% 101% 98% 82% 66% 57% 50% 79% 46,224 Bulawayo 80,600 148% 112% 122% 94% 113% 103% 86% 74% 70% 67% 91% 7,412 Zvimba District 34,730 69% 48% 93% 48% 176% 252% 53% 52% 51% 42% 73% 9,299 Hurungwe District 34,300 97% 85% 133% 96% 115% 134% 87% 81% 75% 63% 96% 1,426 Mutare District 33,290 75% 69% 98% 76% 143% 128% 82% 72% 88% 71% 90% 3,437 Kwekwe District 32,610 84% 112% 125% 89% 77% 98% 81% 75% 85% 76% 88% 3,940 Gweru District 32,080 78% 80% 84% 61% 94% 99% 98% 77% 86% 75% 92% 2,454 Masvingo District 30,150 105% 87% 100% 71% 91% 92% 79% 61% 87% 70% 82% 5,353 Chegutu District 28,160 173% 123% 184% 88% 135% 145% 104% 88% 58% 51% 105% -1,433 Goromonzi District 27,310 84% 57% 69% 36% 92% 51% 82% 68% 53% 65% 75% 6,861 Gokwe South District 26,100 95% 79% 107% 71% 76% 82% 79% 64% 71% 70% 81% 4,899 Mazowe District 25,390 68% 71% 74% 61% 142% 177% 78% 73% 65% 50% 87% 3,423 Murewa District 24,330 119% 86% 76% 43% 73% 61% 64% 55% 66% 61% 68% 7,715 Makoni District 23,130 91% 72% 118% 91% 223% 262% 67% 63% 86% 83% 95% 1,054 Mberengwa District 23,100 93% 70% 75% 52% 67% 61% 68% 49% 102% 77% 72% 6,437 Chipinge District 22,800 74% 52% 100% 86% 143% 150% 68% 49% 65% 47% 75% 5,736 Marondera District 22,640 174% 177% 117% 107% 98% 99% 81% 56% 60% 69% 83% 3,756 Chiredzi District 22,620 78% 71% 93% 105% 150% 145% 87% 81% 95% 72% 98% 441 Gwanda District 20,390 116% 99% 100% 97% 96% 141% 95% 69% 95% 83% 96% 744 Mount Darwin District 19,630 95% 77% 100% 78% 163% 165% 45% 38% 60% 43% 71% 5,682 Gutu District 18,980 81% 133% 83% 44% 87% 79% 75% 52% 97% 67% 79% 3,936 Tsholotsho District 18,330 118% 93% 78% 32% 170% 139% 68% 44% 131% 105% 91% 1,732 Buhera District 18,080 143% 164% 117% 124% 241% 241% 86% 79% 128% 146% 122% -4,027 Makonde District 18,030 135% 112% 202% 186% 142% 154% 106% 94% 97% 79% 120% -3,565 Beitbridge District 18,000 61% 63% 90% 60% 103% 85% 98% 70% 96% 63% 89% 1,931 Chivi District 16,150 97% 112% 160% 78% 193% 141% 68% 49% 90% 100% 93% 1,084 Bulilima District 14,850 86% 63% 96% 41% 108% 91% 65% 46% 77% 59% 74% 3,915 Zaka District 14,150 111% 121% 94% 45% 113% 101% 98% 65% 147% 95% 102% -229 Mwenezi District 14,050 128% 113% 112% 71% 109% 108% 94% 71% 122% 84% 101% -141 Lupane District 13,540 103% 111% 74% 46% 65% 63% 86% 94% 140% 139% 99% 108 Umguza District 13,380 51% 38% 53% 36% 60% 70% 50% 53% 87% 81% 60% 5,312 Insiza District 13,090 86% 62% 98% 56% 105% 86% 83% 71% 90% 66% 87% 1,696 Kadoma District 12,870 169% 124% 237% 185% 213% 235% 111% 105% 129% 73% 139% -4,978 Mutasa District 12,540 110% 71% 129% 102% 196% 220% 78% 72% 93% 70% 99% 145 Nkayi District 12,490 94% 89% 92% 42% 115% 117% 65% 58% 109% 120% 86% 1,739 Matobo District 12,230 85% 81% 98% 38% 121% 85% 81% 57% 99% 82% 88% 1,525 Mangwe District 11,970 67% 97% 82% 45% 127% 133% 96% 87% 116% 122% 105% -599 Umzingwane District 11,160 118% 73% 112% 43% 85% 53% 58% 55% 122% 72% 74% 2,871 Guruve District 10,830 77% 87% 109% 86% 90% 117% 85% 68% 64% 47% 86% 1,566 Bubi District 9,900 58% 40% 62% 21% 81% 74% 59% 54% 81% 78% 67% 3,277 Proportion of National ART patients supported by PEPFAR 1,200,000 83% 90% 80% 1,000,000 73% 70% 800,000 60% 50% 600,000 38% increase in patients 40% supported in 400,000 12mos 30% 20% 200,000 10% - 0% 2016 2017 PEPFAR MOHCC Trajectory towards 95-95-95 1,600,000 1,437,629 1,400,000 1,338,826 1,200,000 1,136,503 1,000,000 800,000 600,000 400,000 200,000 - PLHIV Current on ART National Target PEPFAR Target 10 Traditionally siloed HTC models vs. an Integrated HTS model An integrated HIV testing model: Self-testing leveraged 1. PITC & CITC across all steps 2. Index Testing & Contact Tracing 3. Targeted outreach for those not coming to facilities All together: High yield in Index Testing—High volumes with PITC FY18Q1 Modality: contribution to positives (yield) % Yield by Modality Facility Index: 0.11% (33%) Comm. Index: 7% (40%) Targeted Mobile: 3% (15%) PITC: 89% (5%) Facility VCT: 0.6% (14%) Comm. VCT: 0.6% (12%) We need all of the modalities in the: % HIV_POS by Modality • Right place • Right time • Right sub-population 12 We are not letting up: Still Finding HTS_POS in High ART Coverage Districts 1200 120% 115% 1000 115% 111% 800 110% 600 105% Number HTS_POS 400 99% 99% 100% 200 95% 0 90% Buhera Chegutu Makonde Mangwe Districts FY17 Q2 FY17 Q3 FY17 Q4 FY18Q1 ART coverage 13 And where we are not performing we are intensifying efforts in facilities Improvement in 7 Harare Sites with intensified PITC • HIV tests average weekly increase from 399 to 2207 • HTS_POS average weekly increase from 28 to 128 • 80% of positives were linked to ART 14 And maximizing community platforms: finding positives through Sexual Network Testing • 8 HIV+ identified • 7 initiated on ART • Ages 22-55 yrs • 4 weeks • 128km covered 15 Where are men being diagnosed? 16 What have we learned? → So what are we doing? Interagency learning & collaboration allows us to more rapidly apply successful approaches • Leveraging the facility platform → scaling up iPITC model • Index testing works → expanding index testing model • Targeted Mobile Testing finds people who won’t come to facilities → using this strategically • Self testing could be a game changer → scaling it up 17 PEPFAR Zimbabwe integrated HIV Testing Model (iHTS) Maximizing successful strategies to find sub-populations MoHCC Health Facilities • Verbal screening and routine testing • HRH & technical assistance Facilities Support Client Initiated Testing (VCT) • Client options: (1) Self-testing; (2) Conventional provider delivered HTC • Key population friendly Index Testing Facility Community • Written invitation sent home • F/u with phone call & home visit • Test return clients • Test sexual partners & at-risk HIV Self-Testing • F/u non-return in Community children • Used strategically in all modalities • PEPFAR procured kits & leverage UNITAID Kits Targeted Community Outreach Contact Tracing • Based on sub-population need • Trace sexual partners in community • Prioritize geographic areas & off hours • Test sexual partners & at-risk children National 46,224 PLHIV Gap 3,000-10,000 PLHIV Gap Adjust the intensity of PEPFAR support & Harare 17 Districts testing modalities to reach 95-95-95 by district & by sub-population High ART Gap High ART Gap 1,500—3,000 PLHIV Gap <1,500 PLHIV Gap 8 Districts 7 Districts 0 PLHIV Gap 7 Districts Maintenance Medium ART Gap Low ART Gap Transition of HTS program inputs from High ART Gap districts to no-ART gap districts 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Case-based 0% surveillance High Medium Low No Gap (>9,500) (3,000-9,499) (1-2,999) Facility-based Testing w/HRH TA only Facility-based Testing Facility Index Community-based testing Comm Index Community-based testing Outreach Transition of HTS program inputs from High ART Gap districts to no-ART gap districts 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Case-based 0% surveillance High Medium Low No Gap (>9,500) (3,000-9,499) (1-2,999) Facility-based Testing w/HRH TA only Facility-based Testing Facility Index Community-based testing Comm Index Community-based testing Outreach Linking all HIV+ to treatment and care Zimbabwe adopted Treat All in 2016 Expanding differentiated models of care OVC partner and health facility linkages 23 As we reach 95-95-95: linkage is improving & yield is declining FY16 Q1: 54% Linkage & 8% yield FY18 Q1:74% Linkage & 6% yield 24 Community ART Initiation Increases Linkage 1200 100% 89% ART initiation rate: 89% Introduction of community ART 90% 1000 80% 70% 800 60% 600 50% 40% 400 Number of individuals 30% Proportion initiated on ART on initiatedProportion 20% 200 10% 0 0% Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Tested HIV Positive Initiated on ART ART Initiation Rate 25 New on ART and Adhering to Treatment Differentiated Models of Care Multi-month Scripting & Dispensing Community & Family Refill Groups 26 Leveraging Community Presence: Defaulter Tracking October 2016—September 2017 October 2017—December 2017 • Total defaulters identified: 9,707 • Total defaulters identified: 1,357 • Total in care: 8,348 (86%) • Total in care: 1,263 (93%) • Returned to care: 5,630 (58%) • Returned to care: 1,099 (81%) • Still in care: 2,718 (28%) • Still in care: 164 (12%) 1% 3% 3% 6% 3% 4% 7% 6% 10% 28% 58% Improved 81% 18% collaboration & documentation 2828 Differentiated Models of Care to Keep People on Treatment