MER_Indicator_Reference_Guide_(Version_2.3_FY19).pdf

MER 2.0 (Version 2.3) September 2018

Monitoring, Evaluation, and Reporting Indicator Reference Guide

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Table of Contents Table of Contents Tables & Figures Abbreviations Acknowledgments Overview

Person-Centered Monitoring Standardized Health Data Exchanges & Surveillance Systems

Disaggregated Monitoring Location:

Age:

Sex:

Key Populations:

Priority Populations:

Types of PEPFAR Support:

Disaggregation Types:

Required Disaggregations:

Conditional Disaggregations:

Optional Disaggregations:

PEPFAR Support to Communities and Sites

DSD:

TA-SDI:

Support in Centrally Supported Areas:

Host Country National Program Host Country Targets Host Country Results

MER Indicator Narratives Guiding Narrative Questions Implementing Mechanism (IM) Narratives Technical Area Narratives Host Country Targets & Results Narratives

Justification Narrative Source narrative

Data Quality SIMS in Relation to MER 2.0 DREAMS-Specific Guidance

Key Updates and Changes: MER 2.2 to MER 2.3 Indicator Trainings:

New Indicators:

New Disaggregations:

Changes in Reporting Frequency:

Modifications to Existing Indicators:

Modifications to Existing Disaggregations Retired Indicators Retired Disaggregations Indicator Definition Clarifications Age Disaggregations:

Updated DATIM Functionality:

Auto-Sum Numerators and Denominators:

Auto-Population of HTS_TST Modalities:

How to read a PEPFAR indicator reference sheet

PREVENTION & SUPPORT INDICATORS

AGYW_PREV

file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689119

FPINT_SITE

GEND_GBV

KP_MAT

KP_PREV

OVC_SERV

PP_PREV

PrEP_CURR PrEP_NEW

TB_PREV

VMMC_CIRC

TESTING INDICATORS

CXCA_SCRN (including CXCA_SCRN_POS)

HTS_INDEX

HTS_RECENT

HTS_SELF

HTS_TST (including HTS_TST_POS)

OVC_HIVSTAT

PMTCT_EID

PMTCT_FO

PMTCT_HEI_POS

PMTCT_STAT (including PMTCT_STAT_POS) TB_STAT (including TB_STAT_POS)

TREATMENT INDICATORS

CXCA_TX

PMTCT_ART

TB_ART

TX_CURR

TX_ML

TX_NEW

TX_TB

VIRAL SUPPRESSION INDICATORS

TX_PVLS

HEALTH SYSTEMS INDICATORS

EMR_SITE

HRH_CURR

HRH_PRE

LAB_PTCQI

SC_STOCK

HOST COUNTRY INDICATORS

DIAGNOSED_NAT

TX_CURR_NAT

VL_SUPPRESSION_NAT

PMTCT_STAT_NAT

PMTCT_ART_NAT

VMMC_CIRC_NAT

VMMC_TOTALCIRC_NAT

HRH_STAFF_NAT

KP_MAT_NAT

APPENDICES

Appendix A: Key Populations Classification Document Appendix B: Implementation and Planning Attributes (IMPATT) Appendix C: DREAMS SNU Reporting Requirements Appendix D: Illustrative eligible services for Active OVC beneficiaries (children and caregivers) Appendix E: Global OVC Graduation Benchmarks Matrix Appendix F: Questions and Answers to Possible OVC_SERV Reporting Scenarios file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689131 file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689143 file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689151 file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689153 file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689159 file:///C:/Users/krist/Desktop/MER%202.3%20Indicator%20Reference%20Guide%2009.25.2018%20AM.docx%23_Toc525689169

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Appendix G: Death Registration Coverage by Country Appendix H: Proposed HIV-Specific Short Cause of Death List

Tables & Figures Figure 1: PEPFAR Monitoring: Getting from Process to Impact Figure 2: Patient-Centered Monitoring in PEPFAR Table 1: Host Country indicators by reporting level, targets, and results Table 2: Evolution of PEPFAR Finer Age Bands for Results Reporting Figure 3: Auto-Population of HTS_TST from Associated Indicators Table 3: Indicator Summary Table Table 4: Frequency of Reporting Table Figure 4: PEPFAR MER Indicators Infographic

Abbreviations ART antiretroviral therapy

ARV antiretroviral

BF breastfeeding

CBS case-based surveillance

COD cause of death

COP PEPFAR Country Operational Plan

CQI continuous quality improvement

CRVS civil registration and vital statistics

CXCA cervical cancer

DATIM Data for Accountability, Transparency, and Impact

DQA data quality assessment

DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe

DSD direct service delivery

EID early infant diagnosis

EMR electronic medical record

FSW female sex worker

GARPR UNAIDS Global AIDS Response Progress Reporting

GBV gender-based violence

HCW health care worker

HEI HIV-exposed infant

HIVST HIV self-testing

HRH human resources for health

HTS HIV testing services

IM implementing mechanism

IP implementing partner

L&D labor and delivery

LTFU lost to follow-up

KP key populations

MAT medication-assisted treatment

MER monitoring, evaluation, and reporting indicators

MOH Ministry of Health

MSM men who have sex with men

OVC orphans and vulnerable children

PEP post-exposure prophylaxis

PEPFAR United States President’s Emergency Plan for AIDS Relief

PITC provider-initiated testing and counseling

PLHIV people living with HIV

PMTCT prevention of mother-to-child transmission

POCT point-of-care testing

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PP priority populations

PrEP pre-exposure prophylaxis

PT proficiency testing

PVLS patient viral load suppression

PWID people who inject drugs

SID sustainability index

SIMS site improvement through monitoring systems

STI sexually transmitted infection

TA-SDI technical assistance for service delivery improvement

TB tuberculosis

TG transgender people

TX treatment

UNAIDS Joint United Nations Programme on HIV/AIDS

USG United States Government

VL viral load

VMMC voluntary medical male circumcision

WHO World Health Organization

Acknowledgments MER Indicator Refresh Headquarters Team: Kristine Clark (S/GAC), Jennifer Lim (DOD), Catherine Nichols (USAID), Kimi Sato (Peace Corps), Nadia Solehdin (CDC), Leigh Tally (CDC)

MER Indicator Refresh Field Committee: Nicasky Celestin (CDC: Haiti), Trust Chiguvare (CDC:

Zimbabwe), Ferreira (USAID: Mozambique), Lungowe Mwenda-Mwapela (PCO: Zambia), Bill Elur (CDC:

Uganda), Rachel Kwezi (CDC: Uganda), Apollinaire Kavungerwa (USAID: Burundi), Sam Kudhlande (CDC:

Eswatini), Kate Mbaire (PCO: Kenya), Mutsa Mhangara (USAID: Zimbabwe), Kondwani Nkanaunena (CDC:

Malawi), Joseph Nondi (DOD: Tanzania); Ifeanyi Okoye (DOD: Nigeria), Kim Perez (USAID: South Africa), Sarah Porter (CDC: South Africa)

S/GAC Technical Area Leads: Jenny Albertini, George Alemnji, Gretchen Bachman, Sean

Cavanaugh, Caroline Cooney, Erin Eckstein, Mike Grillo, Lenny Kosicki, Janet Saul, Annie Sanicki, George Siberry, Nora Toiv, Heather Watts, Vamsi Vasireddy

Indicator Training Leads and Training Content Development: Shabeen Ally (HTS), Jenny

Albertini (Cervical Cancer, PMTCT, Prevention), Gretchen Bachman (OVC), Sean Cavanaugh (TB, Treatment), Kristine Clark (Cervical Cancer), Caroline Cooney (DREAMS and OVC), Erin Eckstein (Key Populations), Amanda Geller (PMTCT), Mike Grillo (HTS), Parviez Hosseini (HRH), Peter Minchella (Laboratory), Jennifer Lim (VMMC), Catherine Nichols (TB), Katie O’Connor (PMTCT), Kimi Sato (Prevention), Nadia Solehdin (Treatment), Leigh Tally (PMTCT, Heather Watts (VMMC), Vamsi Vasireddy (HRH), Pooja Vinayak (Key Populations), Sherry Yin (Recency Testing)

Epidemic Control Team Members: Thank you to the many epidemic control team members that contributed their time and expertise into developing and refining the MER indicators.

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Overview Over the past three years, site and population monitoring has effectively changed the way PEPFAR invests in communities to prevent HIV and reach epidemic control. PEPFAR is partnering with the international community to accelerate towards the UNAIDS 95-95-95 global goals: 95 percent of people living with HIV know their HIV status, 95 percent of people who know their HIV status are accessing treatment, and 95 percent of people on treatment have suppressed viral loads. Progress towards epidemic control will be successfully measured, in part, through an effective strategic information framework that not only monitors program outputs, but also key outcomes and programmatic impact.

Figure 1: PEPFAR Monitoring: Getting from Process to Impact

Given the global HIV progress over the past decade, planning, monitoring and resource allocation must occur at the subnational, community, and site levels in order to achieve the greatest impact. Collection and use of disaggregated data that characterizes the populations served in the lowest geographic areas where HIV services are being provided is critical in understanding current program performance and planning for future performance. Consequently, the PEPFAR Monitoring, Evaluation, and Reporting (MER) indicators continue to evolve in order to reflect the progression of U.S. government (USG) support and global HIV response guidelines. Measuring the impact of support at national and regional above-site areas down to direct services at the site-level is paramount to PEPFAR’s program implementation and monitoring approach.

The objectives of the MER guidance document are to streamline and prioritize indicators for PEPFAR programs;

however, MER indicators are not an exhaustive list of all metrics that should be monitored by PEPFAR programs. PEPFAR programs should continually monitor and assess any acute programmatic issues and collect additional data to inform program improvement.

PEPFAR reviews MER indicators on an annual basis to ensure:

• indicators align with the programs planned for implementation and the expectations for both program monitoring and partner management practices;

• indicators reflect any new PEPFAR initiatives and/or emerging programmatic areas;

• indicators align with multilaterals and partner governments to avoid duplication of data collection, where possible; and

• continuous alignment within PEPFAR data streams (e.g., SIMS, expenditure reporting, SID etc.).

Specifically, in 2018, the following issues were taken into consideration:

• the need for further standardization of age, sex and key population disaggregations across the prevention and clinical cascades;

• the need to reduce data collection redundancies between indicators and ensure that the MER guidance and training materials reinforce the relationships within and between indicators;

• the need for enhancements to the data entry screens in DATIM to ensure better data quality; and

• the need for more input on MER changes from community stakeholders, technical experts, implementing partners, and PEPFAR field staff.

PERSON-CENTERED MONITORING

The latest iteration of the MER strives to drive program monitoring to a more patient-centered approach. Per the 2017 WHO Consolidated Guidelines on Person-Centred HIV Patient Monitoring and Case Surveillance, person-centered monitoring refers to a shift from monitoring measuring services (e.g., the number of HIV tests or people on treatment) to monitoring people at the center of their access to linked HIV and health services. In essence, this marks a shift to better support the clients accessing services by focusing more on their individual health outcomes.

PEPFAR’s commitment to person-centered monitoring is evidenced throughout this guidance document through:

• Indicators (i.e., HTS_RECENT) that allow programs to better understand clusters of recently-infected patients and spur programmatic action in order to intervene to stop active infections (i.e., through interventions such as index testing services and test & start).

• New types of outcome-focused cascade analyses (e.g., index testing, prevention).

• A modernized indicator to understand ART patient outcomes and retention in the era of differentiated care (i.e., TX_ML).

• A commitment to ensure data disaggregation by standard five-year age bands in order to further enhance programmatic focus on strengthening patient-level monitoring systems.

• Ensuring COP-funding for health information systems projects is impactful and supports: (1) interoperability between systems; (2) the adoption of standardized disaggregations; (3) shifts away from paper-based to electronic reporting; and (4) the adoption or expansion of HIV surveillance systems.

STANDARDIZED HEALTH DATA EXCHANGES & SURVEILLANCE SYSTEMS

At present, the majority of PEPFAR countries are limited to programmatic aggregate data and periodic surveys to describe the HIV care continuum. With greater emphasis on patient-centered monitoring comes a need to understand patient-level data beyond the aggregate indicators.

Because HIV programmatic aggregate data are not fully de-duplicated (though within antiretroviral treatment programs many are) and do not provide data on the number of people living with HIV or accurate data for total persons diagnosed. Periodic surveys offer individual de-duplicated data, denominators, and the 95-95-95 cascade, but are cross-sectional (one point in time) and are expensive to conduct.

Standardized health data surveillance systems offer countries a mechanism to complement aggregate reporting systems and surveys with quality HIV data that emphasizes individual de-duplicated data to more accurately report the 95-95-95 cascade.

These surveillance systems, when comprehensive, emphasize case finding and case reporting of new diagnoses including recent infections, identify if the newly diagnosed are linked to treatment and provide disaggregation by age, sex, geography, and risk. This in turn can trigger a public health response to effectively intervene and make the necessary adjustments from a surveillance and programmatic perspective to prevent new cases as countries strive to achieve and sustain epidemic control. There are several paths countries can take to obtain standardized health data exchanges and surveillance systems that track individual patients with the removal of duplicates by key HIV sentinel events [first HIV positive diagnoses (by new and chronic infection), first CD4 count (after diagnosis), antiretroviral treatment (ART) initiation, first viral load test, viral suppression

National Environment

Local Environment

PEPFAR Systems

HIV Prevention and Treatment Services

System

Person

Figure 2: Patient-Centered Monitoring in PEPFAR http://apps.who.int/iris/bitstream/handle/10665/255702/9789241512633-eng.pdf;jsessionid=AFDEDBF3A4C281F1EFAAD9F7A8B89810?sequence=1

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(follow up viral load tests), and death]. We describe two paths: (1) case-based surveillance (CBS) and (2) linkage of routine program data. Both approaches allow countries to monitor HIV cases longitudinally, providing real-time estimates of new diagnosis, treatment, and viral suppression by age, sex, and sub-national unit.

Many countries see the need and importance of standardized health data exchanges and surveillance systems but are not sure where to begin, what is needed, or do not have the requisite system attributes. For example, countries lack interoperability within their health systems infrastructure for data linkage between services to occur, methods to uniquely identify patients, and the important endpoint of mortality due to inadequate vital registration systems.

DISAGGREGATED MONITORING

Disaggregation of data is key to understanding if PEPFAR-supported services are reaching the intended beneficiaries and locations. Triangulation of routine program data with underlying geographic, demographic, and epidemiologic data is fundamental to PEPFAR planning, monitoring, and reporting processes. To ensure that no one in need of services in being left behind, PEPFAR requires the routine disaggregation of data by the following categories, where applicable:

Location: PEPFAR clinical indicators are disaggregated to the facility-level. Where services are provided in the community, data are reported at an intermediate community-level (e.g., ward, subdistrict, or district). PEPFAR analyses for planning and support focus on the subnational level (e.g., district).

Age: In order to advance the standardization of patient monitoring and routine health information systems, PEPFAR is adopting standardized reporting by five-year age bands. Beginning in FY19, PEPFAR program should report on the following standard age groups: <1, 1-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40- 44, 45-49, and 50+. It is recommended that country teams review data on life expectancy and new infections to determine if it makes sense for your country to extend in-country and/or national reporting systems beyond the 50+ age band threshold

Sex: PEPFAR Indicators are disaggregated by biological sex (male or female), where applicable.

Key Populations: Reporting of key population disaggregations remains optional but is highly recommended for settings where it is safe to collect this data. The optional key populations disaggregations are: people who inject drugs, men who have sex with men, transgender people, female sex workers, and people in prison and other closed settings. Key populations disaggregations are incorporated into the following indicators: KP_PREV, HTS_TST, TX_NEW, PrEP_NEW, and PrEP_CURR. Disaggregations are not included for TX_CURR as an individual’s status as a key population is subject to change over time.

The PEPFAR key populations reporting guidance is designed to avoid double-counting and ensure that the KP data reported can be meaningfully interpreted. Despite persons potentially falling into more than one KP disaggregate (e.g., an FSW who injects drugs, MSM that is currently incarcerated), implementing partners should be instructed to report an individual in only one KP category with which s/he is most identified. This guidance is applicable to KP_PREV and the KP disaggregates for HTS_TST, TX_NEW, PrEP_NEW, and PrEP_CURR. To better determine the KPs of interest for each indicator the key population classification document found in Appendix A.

Priority Populations: Disaggregation by priority population type is new with FY 2019 reporting. PP_PREV now includes a series of optional priority population types for reporting. Please note that reporting of the priority populations disaggregation is optional but is highly recommended.

Types of PEPFAR Support: To understand the level of support and the type of investments being provided, data are disaggregated by either direct service delivery (DSD) or technical assistance for service delivery improvement (TA-SDI). More information on these categories is provided in the section below.

DISAGGREGATION TYPES:

There are three categories of MER indicator disaggregations, which can be seen in the indicator reference sheets and the DATIM data entry screens.

Required Disaggregations: Required indicates that this indicator disaggregate is required for all countries that have programming for this area. This means that if the country supports a program area, defined by budget and targets set during the COP process, then it is required to report results.

Conditional Disaggregations: Conditional disaggregates include those for which some additional condition must be fulfilled. There are two main types of conditional indicator disaggregations:

a. Disaggregations for those programs that have received initiative-specific funds for special programming such as DREAMS. There is also one full indicator, AGYW_PREV, that is conditional and based on DREAMS funding.

b. Disaggregations that field teams have received permission or a waiver from their OGAC SI Advisor to report on such as reporting on the coarse age disaggregations instead of the finer age disaggregations.

In this case reporting is considered conditional based on approval from OGAC.

Optional Disaggregations: Optional disaggregates should be completed by those for which the indicator is useful to determine the success of their program (e.g., KP or PP population disaggregations) or when it is both relevant and safe to enter the data at the site and/or community level (e.g., KP disaggregations for HTS, TST, PrEP_CURR, PrEP_NEW, and TX_NEW).

PEPFAR SUPPORT TO COMMUNITIES AND SITES

Completing the third full year of quarterly site-level monitoring by all PEPFAR implementing agencies and partners has provided granular data that demonstrate important differences in patient outcomes and site performance. These results should be used to prioritize resources, staff, and interventions among sites to determine the appropriate extent of support and monitoring needed based on site-level outputs and quality outcomes.

There are three categories of PEPFAR support that correspond to attained, scale-up, sustained and centrally supported areas. In areas where PEPFAR is supporting attained, scale-up, and sustained services the type of support should be categorized as Direct Service Delivery (DSD) or Technical Assistance-Service Delivery Improvement (TA-SDI).

In areas where PEPFAR support is not at the site level but is financial support at the national or subnational levels then this support should be characterized as Central Support (CS). DSD and TA-SDI include all sites receiving one or more PEPFAR-supported visits during the year. Importantly, site-level quarterly results and SIMS data should be analyzed and used to determine the number of program support visits needed each year to optimize the quality of HIV/AIDS services and impact. PEPFAR teams should work with implementing partners to ensure that programmatic data (including MER and SIMS results) are being used in this way. The key is to ensure that PEPFAR-supported sites receive the appropriate number of technical assistance visits based on their performance. Refer to the “PEPFAR-support definition” section within each indicator reference sheet for indicator-specific DSD and TA-SDI descriptions.

DSD: Individuals will be counted as receiving direct service delivery support from PEPFAR when BOTH of the below conditions are met: Provision of key staff or commodities AND support to improve the quality of services through site visits as often as deemed necessary by the partner and country team.

TA-SDI: Individuals will be counted as supported through TA-SDI when the point of service delivery receives support from PEPFAR that meets the second criterion ONLY: support to improve the quality of services through site visits as often as deemed necessary by the partner and country team.

1. PEPFAR is directly interacting with the patient or beneficiary in response to their health (physical, psychological, etc.) care needs by providing key staff and/or essential commodities for routine service delivery. Staff who are responsible for the completeness and quality of routine patient records (paper or electronic) can be counted here; however, staff who exclusively fulfill MOH and donor reporting requirements cannot be counted. Each indicator reference sheet includes a list of key staff and/or essential commodities that meet this condition.

AND/OR

2. PEPFAR provides an established presence at and/or routinized support for those services at the point of service delivery. Each indicator reference sheet includes a list of activities that count toward support for service delivery improvement.

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SUPPORT IN CENTRALLY SUPPORTED AREAS: In areas where PEPFAR is providing solely financial support at the national, regional or district level, site level support will be through annual visits.

However, to support government with quality monitoring, it is recommended that results reported through national health information systems should be jointly monitored with host country government on a quarterly basis. SIMS visits may be conducted at these sites if quality issues are identified.

While patient and beneficiary-support activities have transitioned to government or other support, PEPFAR continues to provide support for overarching activities, such as quality assurance and quality improvement (QA/QI) to ensure that patients continue to receive quality services. As such, PEPFAR will continue monitoring activities in centrally supported sites annually via the following indicators: HTS_TST, TX_CURR, TX_NEW, PMTCT_STAT, and PMTCT_ART. Due to the financial investments PEPFAR provides at the above-service delivery area in centrally supported sites and SNUs, it is important that results be provided to ensure that quality assurance initiatives are having the intended impact. PEPFAR programs should be focused on supporting the national program in their respective country to achieve 90% ART coverage (i.e., 95-95-95) for PLHIV; therefore, it is extremely important to understand the services provided to PLHIV across the entire country.

HOST COUNTRY NATIONAL PROGRAM

PEPFAR works closely with host countries, particularly with Ministries of Health, to jointly monitor the HIV response. Monitoring the host country HIV response is critical to understanding both the achievements and the gaps at the subnational level and by population. Host country data are used to inform PEPFAR programs and guide how PEPFAR resources are allocated at all levels. The key program areas for monitoring host country targets and results are: prevention of mother to child transmission programs, key populations, voluntary male medical circumcision and HIV diagnosis and treatment, including viral suppression.

Data are needed from both the national and subnational level. The subnational level is considered the organizational level in which the country team has prioritized their program (PSNU). Data on the host country national program is reported to PEPFAR for all subnational units, regardless of PEPFAR funding supporting these geographical areas; so that the total of the subnational results or targets should equal the total number of national results and targets.

Increasingly, individual-level surveillance data are critical to implement and used in conjunction with MOH to capture data from recent infections to deaths.

At the host country national level, to sufficiently monitor its national response, the host country government’s national set of indicators should include the minimum set of harmonized global indicators (Global AIDS Response Reporting) and additional indicators that represent the needs of the country’s program. The PEPFAR Country team should collaborate with the host country government and other stakeholders to make sure that PEPFAR reporting requirements are taken into consideration in the host country’s national set. In constructing its own comprehensive set of requirements for monitoring the USG response in support of the host country national program, each PEPFAR country team will review all of the PEPFAR essential host country national indicators for applicability to the PEPFAR activities being conducted in the host country.

The PEPFAR host country national and subnational level indicators represent results obtained within the entire host country regardless of PEPFAR support. Both Standard Process and STAR Process Countries should report host country results at Q4 each fiscal year.

Host country results are also reported at the site-level for a subset of indicators. The majority of these facility-level indicators will be reported through the PEPFAR-MOH data alignment process. Standard Process COP Operating Units (i.e., Botswana, Burundi, Cameroon, Cote d'Ivoire, Democratic Republic of the Congo, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe) are required to complete the MOH data alignment process on an annual basis for the following indicators: HTS_TST, TX_CURR, TX_NEW, PMTCT_STAT, and PMTCT_ART.

Beginning in FY19, there will be one additional host country indicator reported at the facility level:

HRH_STAFF_NAT. Please refer to the indicator reference sheet for HRH_STAFF_NAT for more details.

HOST COUNTRY TARGETS

Targets for the host country national and subnational indicators should be reported into DATIM during COP.

Developing targets for the next year at the national and subnational data is an important step in understanding the national program and determining geographic investments (including host country, The Global Fund and other donors). When PEPFAR better understands the target setting process of the national program, then it is better placed to support the program and to fill necessary impactful programmatic gaps. Please describe the target setting process that the host country employs in the narratives and partnering donors). The national targets should cover the next calendar or fiscal year; the timeframe should be indicated in the narratives.

HOST COUNTRY RESULTS

At Q4 of the USG fiscal year, results from the host country systems should be reported up until the most recent month of collection and include 12 months of data. These may not align with end USG fiscal year results. These data should be collected continuously at the subnational level. Data should be in line with GARPR and UNAIDS reported data, where available, although may differ due to different reporting periods. In the narratives, please indicate what months the data include (e.g., October 2017-September 2018; or July 2017 to June 2018). Results should be consistently reported on the same time period to be able to monitor trends over time.

Table 1: Host Country indicators by reporting level, targets, and results

Host Country indicators by reporting level, targets, and results

Host Country Indicator Reporting Level Results vs. Targets

Requirements

Indicator Name National Subnational Facility Targets Results

DIAGNOSED X X X

HTS_TST X

TX_NEW X

TX_CURR X X X X X

VL_SUPPRESSION X X X X

PMTCT_STAT X X X X X

PMTCT_ART X X X X X

VMMC_CIRC X X X X

VMMC_TOTALCIRC X X X X

HRH_STAFF X X

KP_MAT X X X

Red X: Designates those indicators collected through the annual MOH data alignment process

MER INDICATOR NARRATIVES

Three types of narratives are required as part of quarterly submissions: (1) IM level narratives, (2) technical area level narratives, and (3) host country results narratives. Specific requirements are defined for each type of narrative. In addition, guiding narrative questions were introduced for FY18 reporting to provide additional technical detail and continuity within the narrative submitted across PEPFAR countries.

GUIDING NARRATIVE QUESTIONS

Guiding narratives questions have been developed for each PEPFAR indicator to ensure that there is continuity in the technical information reported through the narratives and that this information will be most relevant to subject matter experts in triangulating the narrative data with the quantitative results.

Each indicator has 2-3 questions or prompts, included in the reference sheet, that should guide both implementing partners and USG technical area experts in the development and framing of both the IM and technical area narratives – in addition to the narrative requirements provided in the paragraphs below.

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IMPLEMENTING MECHANISM (IM) NARRATIVES

Narratives are required each quarter. These narratives are an opportunity to convey additional context to accompany the quantitative results. IM level narratives are required for each reported indicator and should:

• Respond to the guiding narrative questions defined in the indicator reference sheet, as applicable.

• Describe current quarterly achievements as well as overall achievements against the fiscal year targets.

• Provide additional information related to specific data quality concerns or programmatic issues that may impact the assessment of partner performance. Indicate whether data quality assessments were conducted during the reporting period and the impact the assessment had on the results and program.

• If appropriate, reference specific site-level issues that were encountered during the reporting period that may prevent achievement of the IM target.

• Provide additional information that is useful for the interpretation of the results on an indicator-specific basis.

• Address any result discrepancies that cannot be reconciled after completing the Data Completeness and Logic Checks.

• Describe the nature of support the partner is providing that qualifies the results to be categorized as Direct Service Delivery (DSD) or Technical Assistance for Service Delivery Improvement (TA-SDI) in accordance with PEPFAR guidance.

TECHNICAL AREA NARRATIVES

Technical area level narratives summarize the PEPFAR OU’s de-duplicated achievements against targets.

These narratives should:

• Respond to the guiding narrative questions defined in the indicator reference sheet, as applicable.

• Provide additional information that would be useful for the interpretation of the results, including specific data quality concerns or programmatic issues that may impact the assessment of overall performance.

• Describe the nature of support the partners are providing that qualifies the results to be categorized as Direct Service Delivery (DSD) or Technical Assistance for Service Delivery Improvement (TA-SDI) in accordance with PEPFAR MER guidance.

• Describe the achievements in light of expected trajectories for the technical area.

• Provide information on data quality assessment (DQA) completion in the last 12 months.

• Address any data discrepancies that cannot be reconciled (at the interagency level) after completing the Data Completeness and Logic Checks.

• Address achievements by prioritization level and DSD and TA-SDI support. For example, is there an overlap between PEPFAR and the Global Fund in support for ART services?

HOST COUNTRY TARGETS & RESULTS NARRATIVES

National level indicator narratives provide an opportunity for teams to discuss the host country response beyond PEPFAR supported activities. For national indicators, both a justification and a source narrative are required for each indicator. Also take note that narratives for both National (_NAT) and Subnational (_SUBNAT) should be recorded in the _NAT narrative section in DATIM.

Justification Narrative

• How does the national number relate to the PEPFAR number?

• What proportion of results does PEPFAR contribute to the national response?

• If the PEPFAR result is larger than the national number, this should be described in detail.

• Note the actual reporting time frame for entered data.

Source narrative

• What is the source of these data?

• When were these data collected/calculated?

DATA QUALITY

Measuring the success of PEPFAR initiatives requires strong monitoring and evaluation (M&E) systems that produce high quality data. Efforts to ensure data quality, therefore, are not singular events occurring randomly.

Rather, these processes need to become institutionalized as part routine data management processes. Once achieved, data quality helps to ensure that limited resources are used effectively, progress toward established goals are accurately monitored, and that decisions are based on strong evidence. Attention to data quality ensures that target-setting and results reporting are informed by valid and sensitive information, and that implanting partners and PEPFAR programs are thinking about and collecting and organizing this information in the same manner. In this way, attention to data quality leads to improved program performance and to more efficient resource management.

Over the past five years, efforts to ensure a data-driven approach to decision making has allowed global HIV programs to dramatically expand their results and impact in a budget-neutral environment. The combination of strengthened monitoring indicators, information regarding site and service delivery quality, site-specific program results, and a more detailed understanding of the geographic distribution of the burden of disease has allowed HIV programs to identify exactly where the HIV epidemic is occurring and where programs can maximize their impact in response.

Data quality has always been a focus of global HIV monitoring and reporting efforts. Specifically, all countries conducting programming supported by PEPFAR are expected to have a data quality strategy in place. For example, data quality assessments should be done routinely conducted and action should be taken as a result of these DQAs. If errors are identified in data, these should be remediated at the point of service delivery as well as in the PEPFAR and host-country reporting systems as soon as possible. Standard operating procedures for routine data quality review should also be in place. Data should be routinely reviewed for errors before submission to ensure that the data passes the data quality checks outlined within the guidance and the Data Review Tool available in DATIM.

More specifically, as many countries are approaching the UNAIDS 95-95-95 goals, it is more important than ever to understand exactly how many people living with HIV are receiving treatment. Furthermore, it’s imperative that countries understand the treatment gaps remaining by location and population to ensure that all PLHIV have equitable access to treatment and are virally suppressed and that scarce resources are allocated appropriately to areas with the greatest unmet need. As such, we are at a very important moment in the HIV response where accuracy of the data is essential in ensuring that programmatic decisions are made effectively.

PEPFAR is committed to ensuring that the data collected through the MER is accurate and timely. It is essential to not only capture high-quality data, but to also continuously use and analyze the data to achieve maximum program impact.

SIMS IN RELATION TO MER 2.0

SIMS evaluates the quality of service delivery or program oversight to identify performance issues that may impact patient outcomes or the integrity of reporting for MER targets or disaggregates. Low final scores (reds and yellows) from these core essential elements (CEEs) highlight potential issues with service delivery, site performance or oversight, and/or documentation of patient results. Site-level triangulation of MER and SIMS data can be used to contextualize performance and could be useful to determine if performance challenges at a site are due to issues related to the underlying quality of service provision. SIMS is currently undergoing revisions for FY19. Once complete, the following will be released: (1) an updated SIMS and MER Linkage Reference Table to describe which CEEs align with each MER indicator (2) an updated SIMS Implementation Guide, which will include recommendations on data triangulation across MER and SIMS data streams to inform strategies for improvement in programs and subsequent performance.

DREAMS-SPECIFIC GUIDANCE

In addition to required MER reporting, it is essential that all implementing partners in DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) SNUs report their results for and use data from all DREAMS-related indicators and their required disaggregations. The current list of DREAMS countries includes:

Botswana, Cote d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

https://datim.zendesk.com/hc/en-us/articles/360014647412-DRT-Users-Guide-August-2018-https://datim.zendesk.com/hc/en-us/articles/360014647412-DRT-Users-Guide-August-2018-

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DREAMS countries are encouraged to monitor interventions progress using custom indicators for program components that do not have existing MER indicators (e.g., contraceptive method mix, condom promotion and provision). Appendix C includes a full list of the DREAMS-related indicators reported for MER 2.0 and the required disaggregation for each indicator. Please note there are also specific reporting requirements for DREAMS narratives.

Key Updates and Changes: MER 2.2 to MER 2.3 Through the past 3 years of quarterly, site-level monitoring, PEPFAR programs have used data to improve implementation. Changes to the MER highlight key program areas (e.g., index testing services) that should be taken to scale. Tables 3 and 4 and Figure 4 on the following pages highlight the key details for the MER indicators.

INDICATOR TRAININGS:

Indicator training videos and content have been created by PEPFAR HQ technical area experts and uploaded on the MER DATIM support page. There is a training available for each technical area (e.g., TB, Treatment, HTS, HRH, etc.). Please note that the MER training videos are available to both USG and implementing partner staff with access to DATIM.

Training content is still being finalized and content is being uploaded to the DATIM support page on a rolling basis, once it becomes available. All training videos and associated training materials will be available by October 31, 2018.

Data entry screens reflecting the changes outlined in this guidance document are under development. Once finalized, screenshots will be captured on the DATIM support site at the following link:

https://datim.zendesk.com/hc/en-us/articles/360001143166-DATIM-Data-Entry-Form-Screen-Shot-Repository.

NEW INDICATORS:

AGYW_PREV: AGYW_PREV is a semi-annual indicator introduced for reporting beginning in FY19.

AGYW_PREV is a DREAMS-specific indicator to measure how many adolescent girls and young women (AGYW) are being served in the DREAMS program and whether all AGYW in DREAMS have received the intended layered services and interventions to ensure that they remain HIV-free.

CXCA_SCRN: CXCA_SCRN is a semi-annual indicator introduced for reporting beginning in Q4 of FY18.

CXCA measures the percentage of HIV-positive women on ART screened for cervical cancer.

CXCA_TX: CXCA_TX is a semi-annual indicator introduced for reporting beginning in Q4 of FY18. CXCA_TX measures the percentage of cervical cancer screen-positive women who are also HIV-positive and on ART that were eligible for and received cryotherapy, thermocoagulation or LEEP.

HTS_INDEX: HTS_INDEX is now a standalone indicator to monitor and help guide PEPFAR programming for index testing services. Reporting for HTS_INDEX will begin in Q1 of FY19. HTS_INDEX is the first MER indicator to monitor PEPFAR programming related to HIV index testing services (often referred to as partner notification or contact tracing services). This indicator includes a cascade that will help to better understand the scale and fidelity of the index testing services provided by PEPFAR-supported programs.

HTS_RECENT: HTS_RECENT is a quarterly indicator introduced for reporting beginning in Q1 of FY19.

Testing individuals that are newly diagnosed with HIV-1 for recent infection is an emerging programmatic area of emphasis for PEPFAR. HTS_RECENT measures the percentage of newly diagnosed HIV-positive persons aged ≥15 years with a test for recent infection result of ‘recent infection’ during the reporting period. As countries progress toward epidemic control, surveillance of newly diagnosed persons will ensure that interventions target those at highest risk of acquiring or transmitting HIV infection. One approach is to identify recent HIV infections, defined as those acquired within approximately the last one year. Incorporation of rapid tests for recent HIV-1 infection into routine HIV testing services will enable the establishment of a surveillance system to quickly detect, monitor, characterize, and intervene on recent infections among newly diagnosed HIV cases. Data collected from a recent infection surveillance system can also be used to fine-tune a country’s programmatic response through prioritized programming and resource allocation.

PrEP_CURR: PrEP_CURR is a semi-annual indicator introduced for reporting beginning in FY19.

PrEP_CURR measures the number of individuals receiving oral PrEP during the reporting period and is an important addition to the MER to help PEPFAR programs understand how many clients are being sustained on PrEP after initiation.

https://datim.zendesk.com/hc/en-us/sections/200929315-MER https://datim.zendesk.com/hc/en-us/articles/360001143166-DATIM-Data-Entry-Form-Screen-Shot-Repository

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TX_ML: TX_ML is a semi-annual indicator introduced for reporting beginning in FY19. TX_ML is intended to drive improved tracing of patients to ensure patient outcomes are accurately documented. It is the first PEPFAR indicator to collect information on mortality among patients on ART and in care. The indicator also strives to better understand the magnitude of previously undocumented patient transfers.

NEW DISAGGREGATIONS:

HTS_TST: A new facility-based testing modality has been introduced: Post ANC1: Pregnancy/L&D/BF. Please refer to the HTS_TST indicator reference sheet for additional details.

PP_PREV: A new, optional priority populations type disaggregate was added to this indicator to capture the specific priority populations accessing prevention services. Age/sex-specific priority populations were not added to this disaggregate group (e.g., AGYW) because these can be calculated using the mandatory age/sex disaggregates collected within the indicator.

TX_TB: The denominator has been updated to include a new disaggregate for “positive result returned.”

CHANGES IN REPORTING FREQUENCY:

See Table 4 for more details on indicator reporting frequency.

PrEP_NEW: The reporting frequency moves from quarterly to semi-annually in FY19 to align the prevention indicators.

TB_ART: The reporting frequency moves from semi-annually to quarterly in FY19 to align with the ART-related indicators and TB_STAT.

TB_STAT: The reporting frequency moves from semi-annually to quarterly in FY19 to align with HTS_TST.

TX_PVLS: The reporting frequency moves from annually to quarterly in FY19 to ensure that the treatment cascade can be reviewed quarterly and to emphasize the importance of regularly monitoring viral load coverage and suppression.

MODIFICATIONS TO EXISTING INDICATORS:

HRH_CURR: The reporting of HRH_CURR by the number of full-time equivalents is no longer required.

HRH_CURR has been simplified to collect the total number of staff (regardless of FTE). In addition, a new data element has been added to capture the amount of funding spent on health care workers by cadre and support type.

PMTCT_EID: The denominator has been updated to include HIV+ pregnant women identified after ANC1, including those women who test positives later in pregnancy, at labor and delivery, and throughout the breastfeeding period. The positive results for these women will be captured under the newly added HTS modality, Post ANC1: Pregnancy/L&D/BF and will be summed with the positives (new and known) from ANC1 (i.e., PMTCT_STAT_POS) to obtain the total denominator.

MODIFICATIONS TO EXISTING DISAGGREGATIONS

OVC_HIVSTAT: The status type disaggregates have been modified. The sub-disaggregate under “No status reported” formerly called “Test not indicated” will now be “Test not required based on risk assessment” to simplify the language.

OVC_SERV: Age/sex and program status (i.e., active or graduated) disaggregations have been combined.

PMTCT_ART: Age disaggregations were added to the “maternal regimen type” disaggregate to align with PMTCT_STAT. Age disaggregations were not previously collected for PMTCT_ART.

PREP_NEW: The KP type disaggregation for this indicator has been updated. “Other key population” has been removed and replaced with “people who inject drugs” and “people in prisons and other closed settings” so that all key population disaggregate group options align between HTS_TST, TX_NEW, PrEP_CURR, and PrEP_NEW.

TB_ART: Age/sex and “ART status” disaggregations have been combined.

TB_PREV: Age/sex and “Type of TB preventive therapy by ART Start” disaggregations have been combined for both the numerator and the denominator.

TB_STAT: Age/sex disaggregations were updated from coarse-only to fine age bands to allow TB_STAT to auto-populate HTS_TST via the TB modality and to align with the age bands for TB_ART.

TX_TB: Age/sex and “ART Status” disaggregations have been combined for the numerator. Age/sex and “Start of ART by Screen Results” disaggregations have been combined for the denominator.

VMMC_CIRC: Age disaggregations were added to the “HIV Status and Outcome” disaggregate in order for VMMC HTS results to auto-populate into the HTS_TST indicator. Note that the age disaggregations align with HTS_TST to allow for auto-population. This means the <4 disaggregations differ slightly from the indicator itself.

RETIRED INDICATORS

TX_RET: Indicator has been removed in order to incorporate the new TX_ML indicator and strengthen reporting on TX_PVLS.

RETIRED DISAGGREGATIONS

OVC_SERV: The age/sex/service DREAMS-related disaggregate was removed and replaced with a new indicator, AGYW_PREV, to improve the tracking of layered services and interventions.

PMTCT_STAT: The age-only disaggregate was removed to minimize duplicative reporting. Age is already captured under the status and age disaggregate group.

TX_NEW: The “confirmed diagnosis of TB” disaggregate was removed as TB_ART results have moved to quarterly reporting.

INDICATOR DEFINITION CLARIFICATIONS

GEND_GBV: Clarifying language was added to the “disaggregate descriptions and definitions” section of the indicator to ensure that clients are not double-counted under the indicator.

OVC_SERV: Clarifying language added to this indicator reference sheet to better emphasize that only children (and their caregivers) that actually received one or more services in each of the preceding two quarters should be counted in this indicator. OVC that have registered for the program (i.e., been enrolled and assessed) but have not yet received any services should not be counted in the results. The purpose of this indicator is to assure that beneficiaries are being reached promptly and regularly with needed support.

In addition, illustrative eligible interventions that qualify a beneficiary to be counted as active have been added, for both children and caregivers. For services that are not captured in the list, local USG funding agency approval must be received in order to count these services toward active OVC status.

Next, minimum graduation benchmarks have been established to ensure that PEPFAR programs have aligned objectives for progressing children and their caregivers to a minimum level of stability. Children and caregivers in a household move from active to graduated status together when each has met the minimum benchmarks (reflecting the family-centered nature of OVC programming).

Lastly, clarifying language has been added to the indicator reference sheet…