ATTACHMENT J.3 - CHASS FY 17 Q4 Quarterly Report.pdf

Clinical & Community HIV & AIDS Services Strengthening (CHASS) Quarter 4, FY17 Progress Report

FHI 360 Moçambique │ Rua Beijo da Mulata Plot # 5900 │ Somersheild, Maputo, Mozambique T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org

LIFE OF PROJECT SUMMARY

Implementing Partner: Family Health International (FHI 360)

Activity Name: Clinical and Community HIV/AIDS Services Strengthening (CHASS) Project

Activity Goal: CHASS’s goal is to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in four provinces.

Activity Objectives: To contribute toward HIV/AIDS epidemic control in Mozambique, CHASS seeks to:

1) Increase coverage of antiretroviral treatment (ART) to 90 percent.

2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively.

3) Increase the average CD4 count at initiation of ART from 350 to 500 cells per cubic millimeter.

4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB.

5) Operationalize viral load testing.

Life of Activity (start and end dates): August 2010–July 2019

Total Estimated Contract/Agreement Amount: US$195,000,000

Total Amount Obligated (to date (Sep 30): US$115,310,555.00

Current Pipeline Amount: US$10,629,929

Actual Expenditure through This Quarter: US$14,928,893.54

Estimated Expenditures Next Quarter: US$12,000,000

Geographic Focus: Niassa, Tete, Manica, Zambezia, and Sofala Provinces, Mozambique

Report Submitted by: Dr. Joaquim Fernando

November 10, 2017

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CONTENTS

LIST OF FIGURES

LIST OF TABLES

LIST OF ACRONYMS AND ABBREVIATIONS

EXECUTIVE SUMMARY

PROJECT OVERVIEW

PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA

IR1: STRENGTHEN FACILITY-BASED HIV SERVICES

HIV Testing and Counseling Performance in counseling and testing Variation by geographic area Performance against HTC targets Challenges related to HTC Key HTC activities for the next quarter

Care and Treatment Performance in care and treatment Variation by geographic area and interventions Performance against care and treatment targets Challenges related to care and treatment Key care and treatment activities in the next quarter

Pediatric Antiretroviral Therapy Performance in pediatric care and treatment Variation by geographic area and Intervention Performance against pediatric care and treatment targets Challenges related to pediatric care and treatment Key pediatric care and treatment activities for the next quarter

Prevention of Mother-to-Child Transmission Performance in PMTCT Variation by geographic area and Intervention Performance against PMTCT targets Challenges related to PMTCT Key PMTCT activities for the next quarter

TB/HIV Integration Performance in TB/HIV integration Variation by geographic area and Intervention Performance against TB/HIV targets Challenges related to TB/HIV Key TB/HIV activities for the next quarter Challenges related to nutrition Key nutrition activities planned for next quarter

Health Systems Strengthening Improving quality and efficiency in HIV service delivery Addressing gaps in human resources for health Supporting health and HIV/AIDS planning and accountability activities

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Improving HF leadership and management Health Commodities Management and Pharmaceutical Services

Strengthening drug and commodity management Decentralization of ARV drug distribution and dispensing Support for the 3-month dispensing initiative Strengthening the use of FILAs to identify and track defaulters Promoting and supporting pharmacovigilance and patient safety National-level pharmacy-related activities

Laboratory Services HSS-related next steps/key activities for the next quarter

HIV PREVENTION

DREAMS

Gender and GBV

Performance in GBV Challenges related to gender

STRATEGIC INFORMATION

Electronic Patient Tracking System Transition to DATIM Internal M&E Strengthening Data use Support to MISAU M&E Research

PROJECT MANAGEMENT AND IMPLEMENTATION

Zambezia expansion start-up/transition Developing FY18 work plan USAID financial review Sub-agreement management with DPS Sub-agreement management with SDSMAS Sub-agreement management with CBOs

Key program management activities for the next quarter

MAJOR PRIORITIES/ACTIVITIES PLANNED FOR NEXT QUARTER

ANNEXES

Annex 1. Provincial care and treatment cascades Annex 2. HFs that received prefabs and how these are being used Annex 3. Number of patients enrolled in 3-month dispensing in CHASS-supported HFs

LIST OF FIGURES

Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q4 Error! Bookmark not defined.

Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q4 .................................... Error! Bookmark not defined.

Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and facilities providing ART services, FY17 Q4 ............................................................ Error! Bookmark not defined.

Figure 4. HIV positivity yield by sector and quarter, over the past year ............. Error! Bookmark not defined.

Figure 5. Performance against target in HTC, by sector, FY17 Q4 ...................... Error! Bookmark not defined.

Figure 6. ART cascade, FY17 Q4 ............................................................................ Error! Bookmark not defined.

Figure 7. Number of patients newly enrolled in ART by quarter and province, FY16 and FY17 ............. Error!

Bookmark not defined.

Figure 8. 12-month retention rates over time, by province ................................ Error! Bookmark not defined.

Figure 9. Twelve-month retention rates by district, SAPR and APR 2017 .......... Error! Bookmark not defined.

Figure 10. Performance against target for new enrollees on ART by province, FY17 Q4 Error! Bookmark not defined.

Figure 11. Number of children with advanced HIV infection newly enrolled on ART, by project FY16 and FY17 ........................................................................................................................ Error! Bookmark not defined.

Figure 12. PMTCT cascade, FY17 Q4 ..................................................................... Error! Bookmark not defined.

Figure 13. Option B+ coverage among HIV-positive pregnant women, by province and quarter .......... Error!

Bookmark not defined.

Figure 14. Number of infants born to HIV-positive women who received an HIV test within 12 months of birth, FY17 Q4 ........................................................................................................ Error! Bookmark not defined.

Figure 15. TB cascade, FY17 Q4 ............................................................................ Error! Bookmark not defined.

Figure 16. TB patients registered, by province and quarter ................................ Error! Bookmark not defined.

Figure 17. Number of ADR notifications in Q4, the Annual achievements and percentage of targets achieved by province ............................................................................................. Error! Bookmark not defined.

Figure 18. Growth in Index Case testing from Q1 to Q4, by province ................ Error! Bookmark not defined.

Figure 19. Busca cascade per province, FY17 Q4 ................................................. Error! Bookmark not defined.

Figure 20. Map of EPTS sites by year of hand over .............................................. Error! Bookmark not defined.

Figure 21. Growth in EPTS coverage of eligible sites and patients currently on ART from 2016 to present ................................................................................................................................ Error! Bookmark not defined.

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LIST OF TABLES

Table 1. Performance on selected indicators at the end of FY17 Q4 ................. Error! Bookmark not defined.

Table 2. Testing results by sector in Q1 through Q4, 2017 ................................. Error! Bookmark not defined.

Table 3. Yield and contribution to cases identified by modality, FY17 Q4 and Year to Date . Error! Bookmark not defined.

Table 4. Summary of testing by sector in sites with disaggregated data, FY17 Q4 .......... Error! Bookmark not defined.

Table 5. Performance against target by province and testing modality, FY17 Q4 ........... Error! Bookmark not defined.

Table 6. Performance against target in ten districts with largets targets, FY17 Q4 ......... Error! Bookmark not defined.

Table 7. GAAC enrollment by province, FY17 Q4 ................................................. Error! Bookmark not defined.

Table 8. Viral load results by province, FY17 Q4 .................................................. Error! Bookmark not defined.

Table 9. Linkages and referrals between CHASS and COVida projects, FY17 Q3 and Q4 Error! Bookmark not defined.

Table 10. Performance of key PMTCT indicators by province, FY17 Q4 ............. Error! Bookmark not defined.

Table 11. Number of patients enrolled in three-month dispensing by CHASS-supported province, FY17 Q4 and to date ............................................................................................................. Error! Bookmark not defined.

Table 12. Gene Xpert samples processed and results, Q3 and Q4 ..................... Error! Bookmark not defined.

Table 13. VSL groups by quarter, FY17 ................................................................. Error! Bookmark not defined.

Table 14. Estimated coverage of index case testing by province in those districts with index case testing, FY17 Q4 .................................................................................................................. Error! Bookmark not defined.

Table 15. Results of a referral sub-system linking traditional healers and community counselors in Manica, Q4 ........................................................................................................................... Error! Bookmark not defined.

Table 16. Referrals reported for HF services—referrals made and patient-referrals received, FY17 Q4 ................................................................................................................................ Error! Bookmark not defined.

Table 17. Results of busca consentida by group, FY17 Q4 .................................. Error! Bookmark not defined.

Table 18. Funds disbursed to DPS, FY17 ............................................................... Error! Bookmark not defined.

Table 19. Funds Disbursed with SDSMAS, FY17 ................................................... Error! Bookmark not defined.

LIST OF ACRONYMS AND ABBREVIATIONS

ADR Adverse Drug Reaction AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral CBO Community-Based Organization CCR Consulta da Criança em Risco (High-Risk Consultation for Children) CD4 Cluster of Differentiation 4 CHASS Clinical and Community HIV/AIDS Services Strengthening C-HTC Community HIV Testing and Counseling CMAM Centro de Medicamentos e Artigos Medicos (Central medical stores) CS Centro de Saúde (Health Centre) DATIM Data for Accountability, Transparency and Impact Monitoring DDM Direcção Distrital de Medicamentos (District Drug Directorate) DPM Direcção Provincial de Medicamentos (Provincial Drug Directorate) DPS Direcção Provincial da Saúde (Provincial Health Directorate) DSD Direct Service Delivery EID Early Infant Diagnosis EPTS Electronic Patient Tracking System FILA Ficha Individual de Levantamento de ARVs (individual patient drug pick-up records) FY Fiscal Year GAAC Grupo de Apoio e Adesão da Comunidade (Community Support and

Adherence Group) HIV Human Immunodeficiency Virus HTC HIV Testing and Counseling IR Intermediate Result LRDA Livro de registo de ARVs; daily antiretroviral register M&E Monitoring and Evaluation MCH Maternal and Child Health MISAU Ministerio da Saúde (Ministry of Health) MMIA antiretroviral (ARV) and RTK consumption data report forms (MMIAs) PCR Polymerase Chain Reaction PDSA Plan-Do-Study-Act PEPFAR U.S. President’s Emergency Plan for AIDS Relief PICT Provider-Initiated Counseling and Testing PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission POC Point-of-Care PS Posto de Saude (Health Post) RTK Rapid Test Kit

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SDSMAS Serviços Distritais de Saude, Mulheres Acão Social (District Directorate for Health, Women, and Social Action Services)

SMS Short Message Service TA Technical Assistance TB Tuberculosis TSV Technical Support Visit UCSF University of California at San Francisco USAID U.S. Agency for International Development VCT Voluntary Counseling and Testing VSL Village Savings and Loan WHO World Health Organization

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EXECUTIVE SUMMARY

In this report, the Clinical and Community HIV/AIDS Services Strengthening (CHASS) project presents achievements for the fourth quarter of fiscal year (FY) 17. The last quarter of FY17 saw increased testing but stable positivity and a constant number of patients diagnosed as HIV-positive. The estimated percentage of patients linked to care was somewhat lower than in the earlier quarters this year, which is likely the result of catching up with the backlog of eligible patients who had not been enrolled. Overall, CHASS overachieved relative to the target for the number of patients currently on antiretroviral therapy (ART) but the gap in direct service delivery (DSD) sites (82 percent of the target achieved) highlights the need for redoubled efforts and new approaches in FY18 to meet the targets for 90:90:90.

In the fourth quarter of FY17, CHASS again surpassed its targets in terms of the number of individuals who received HIV testing and counseling (HTC) and received their test results by more than 32 percent, with 516,503 people tested across all sectors in CHASS-supported sites. Continued growth in testing is part of the strategy required to ensure that the ambitious targets for the number of new enrollees are achieved. In fact, in Q4, the number of people newly enrolled on ART was at or above target in all provinces except Manica, which achieved 76 percent of the quarterly target.

With 28,805 people testing positive for HIV and 20,979 (75 percent) of them enrolled in care across the four provinces (Figure 1), this is an increase from past quarters. The number and percentage of patients newly initiating on ART decreased slightly after a huge increase in Q2 with 19,678 patients (70 percent of those newly diagnosed)—a decline from prior quarters, which is likely due to the limited number of patients who are now in the backlog. Without these patients, these percentages are expected to level off and truly reflect increases in the future.

Figure 1. HIV care and treatment cascade for all CHASS provinces combined, FY17 Q4

Again this quarter, CHASS-supported sites showed good performance in terms of the percentage of HIV-positive pregnant women who received antiretroviral (ARV) drugs to reduce the risk of mother-to-child-transmission, with 98 percent of HIV-positive pregnant and lactating women receiving ARV drugs. The quarterly cascade for the prevention of mother-to-child transmission (PMTCT; Figure 2) showed

T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org improvement this quarter in testing of exposed infants (an issue highlighted in Q2). However, challenges remain given that 7 percent of all infants tested within 12 months of birth and whose results were HIV-positive, as well as the percentage of results received within the quarter, were low.

Figure 2. PMTCT cascade, all CHASS provinces, FY17 Q4

More details of CHASS’s performance toward targets are in Table 1, which summarizes performance for key indicators in Q4 of FY17 for all CHASS provinces. Achievements in green reflect achievements at or above 85 percent of the quarterly target, while those in red reflect areas where CHASS achieved less than 85 percent of the quarterly target. For the majority of these key indicators, CHASS achieved the annual targets for 2017. All of the results presented here are detailed in the following sections of the report, where performance is explained and actions needed are discussed.

NOTE: CHASS has continued to use the indicators, as reported in the past quarters, in order to allow for analysis of trends over time. In some cases, this means that indicators are not reported according to the U.S. government Monitoring, Evaluation and Reporting (MER) guidance. For example, the number of infants tested in the PMTCT cascade is the total number of children tested via polymerase chain reaction (PCR) and rapid tests, whereas the MER indicator for early infant diagnosis (EID) only includes PCR.

Another difference is in provider-initiated counselling and testing (PICT). Past reports and this report include repeat tests in antenatal care (ANC), which are not included in the MER PICT indicator.

Conversely, past reports and this report do not include tests in maternity and tests of partners of women seen in ANC settings, both of which are included under “Other PICT” in the MER indicator.

CHASS will be revising its reporting moving forward to allow for a clearer discussion of MER indicators.

Moreover, because all sites previously reported as receiving “other support” are reported as technical assistance (TA) sites in MER, we have combined them here as well. As a result, it is not possible to compare the results to the TA targets, which do not include the targets for these sites.

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Table 1. Performance on selected indicators at the end of FY17 Q4

Indicator Annual Target Q1 Q2 Q3 Q4

Q4 % of annual target achieved Annual achievement Annual % achievement* % of adults and children who are alive and in care 12 months after initiation 80% 67% 69% 87% 69% 87% Manica 80% 62% 66% 83% 66% 83% Niassa 80% 74% 74% 93% 74% 93% Sofala 80% 65% 65% 82% 65% 82% Tete 80% 78% 77% 97% 77% 97% # of individuals who received counseling and testing (C&T) services for HIV and received their test results 1,128,442 344,857 419,483 413,076 516,503 46% 1,693,919 150% Manica 712,537 133,679 173,469 153,350 185,063 26% 645,561 91% Niassa 43,270 45,995 43,888 41,314 61,698 143% 192,895 446% Sofala 219,808 84,374 102,136 108,122 143,472 65% 438,104 199% Tete 152,827 80,809 99,990 110,290 126,270 83% 417,359 273% # of individuals with advanced HIV infection currently receiving ART 238,233 209,886 217,807 242,789 251,419 251,419 106% Manica 86,816 70,666 77,875 78,292 80,053 80,053 92% Niassa 11,614 19,411 20,785 21,775 22,339 22,339 192% Sofala 92,860 80,541 82,601 88,390 92,484 92,484 100% Tete 46,943 51,968 52,273 54,332 56,543 56,543 120% # adults and children w/advanced HIV infection newly enrolled on ART 79,277 18,154 23,039 22,436 19,678 25% 83,307 105% Manica 35,392 6,325 8,502 7,883 6,797 19% 29,507 83% Niassa 3,389 1,981 1,872 1,829 1,806 53% 7,488 221% Sofala 29,697 6,216 8,336 8,444 7,269 24% 30,265 102% Tete 10,799 3,632 4,329 4,280 3,806 35% 16,047 149% % of pregnant women with known HIV status 99% 97% 98% 98% 99% 100% 98% 99% Manica 99% 99% 99% 97% 100% 101% 99% 100% Niassa 99% 101% 95% 99% 99% 100% 98% 99% Sofala 99% 93% 99% 98% 100% 101% 98% 99% Tete 99% 95% 99% 99% 98% 99% 98% 99% % of HIV-positive pregnant women who received ARV drugs to reduce risk of mother-to-child-transmission 99% 97% 98% 97% 98% 99% 98% 99% Manica 99% 97% 99% 96% 99% 100% 98% 99% Niassa 99% 94% 95% 95% 94% 95% 95% 96% Sofala 99% 98% 98% 98% 98% 99% 98% 99% Tete 99% 97% 99% 98% 100% 101% 98% 99% % of tuberculosis (TB)/HIV co-infected patients on ART 100% NA 90% 92% 92% 91% 91% Manica 100% NA 92% 93% 93% 92% 92% Niassa 100% NA 88% 90% 90% 89% 89% Sofala 100% NA 90% 92% 92% 91% 91% Tete 100% NA 91% 90% 90% 90% 90% *All achievement figures include all CHASS-supported sites regardless of whether or not they had targets for FY17.

Comment [1]: What is the threshold for a red highlight in your performance table? 20% or better? Consider using a higher performance threshold for conditional highlighting on future reports for ease of analysis.

Comment [EO4]: I have revised but to keep the table on one page we have used short titles. With the revision, even with the changes accepted, the footnote drops to the next page. This is the case in Q2 and Q4 when all indicators are included. We can look at this again when we adjust to MER indicators next quarter.

Comment [3]: _Marked as resolved_ I see this is % of total annual target (i.e. 25% threshold); this performance indicator should be presented as the % achieved of the quarterly target, or as % achieved of the cumulative annual target to date.

Comment [EO2]: We use the 85%, 115% thresholds used by PEPFAR. This is documented in the text that proceeds the table-please see the highlighted text.

Comment [5]: _Re-opened_

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In Q4, CHASS technical and program teams continued to address performance gaps illuminated in the Q3 performance report. These include implementing strategies for achieving FY17 targets in HIV case identification among infants, increasing children and adults newly initiated on ART, increasing the number of PLHIV on isoniazid preventive therapy for TB, and improving retention on ART. Specific activities implemented by the different CHASS teams are described in the sections for the respective programs below.

To address the long-standing challenges of inadequate space, infrastructure, and furniture in high-volume health facilities (HFs), CHASS completed delivery and installation of 50 prefabricated housing units (Sofala: 13; Manica: 13; Tete: 15; Niassa: 9) and renovation of 60 health facilities (Sofala: 20;

Manica: 22; Tete: 15; Niassa: 3). HF renovations included painting, carpentry, electricity repairs, and water systems repairs. The prefabs are being used for confidential HTC, consultations, serviços amigos do adolescente e jovem (youth-friendly health services) (SAAJ), the electronic patient tracking system (EPTS), and pharmacy services.

During the quarter, CHASS effectively extended its operations into five districts of Zambezia. By the end of the quarter, the project had accomplished several transition/start-up activities including hiring of essential personnel; major procurements such as vehicles, a boat/engines, and furniture; establishment of offices in Quelimane, Mopeia, Chinde, and Morrumbala; and selection of subawardees to implement some of the planned activities. CHASS participated in various meetings including those convened by the direcção provincial da saúde (provincial health directorate) (DPS), transition meetings between Friends of Global Health (FGH) and FHI 360, and Zambezia Action Plan (ZAP) meetings.

The main challenge during the quarter was the continuing shortage of surgical gloves in almost all HFs.

CHASS is responding by procuring an additional 450,000 pairs of gloves to be distributed to needy HFs within the five provinces.

PROJECT OVERVIEW

The Clinical and Community HIV/AIDS Services Strengthening (CHASS) project aims to improve the quality, coverage, and effectiveness of high-impact, evidence-based HIV/AIDS interventions in the five provinces of Sofala, Manica, Tete, Zambezia, and Niassa by ensuring that the right HIV/AIDS interventions are implemented, at the right time and in the right places, so as to contribute to the desired goal of epidemic control in Mozambique. This nine-year, US$195,000,000 USAID-funded project began on August 1, 2010, and will end on July 31, 2019.

CHASS is pursuing five objectives:

1) Increase coverage of antiretroviral therapy (ART) to 90 percent.

2) Increase retention on ART to 80 percent and 70 percent at 12-month and 36-month follow-up, respectively.

3) Increase the average cluster of differentiation 4 (CD4) count at initiation of ART from 350 to 500 cells per cubic millimeter.

4) Complete tuberculosis (TB) treatment for 90 percent of people living with HIV (PLHIV) diagnosed with TB.

5) Operationalize viral load testing.

Comment [6]: It is interesting that CHASS is allocating a similar level of investment for Sofala and Manica, whereas Manica has more than 3x the testing targets. Are resources mainly being allocated based on C&T needs assessments (2nd and 3rd 90)?

Comment [8]: This is a question that can be answered in separate discussions - no need to revise the report here.

Comment [ST7]: This allocation pertains to only prefabs and HF renovations. It does not reflect CHASS’s overall resource allocation across the four provinces. Also, the prefabs were requested by the respective DPSs to address different needs, of which HTC is just one.

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CHASS supports:

366 ART sites 397 PMTCT sites 397 HIV testing and counselling sites 56 districts

To achieve these objectives, CHASS combines technical capacity strengthening of health facilities (HFs) and community-based organizations (CBOs), direct support for quality and integrated HIV/AIDS service delivery, and health systems strengthening (HSS) at provincial, district, and HF levels. The project is implemented jointly with local organizations, district health teams, provincial health teams, and the Ministerio da Saúde (Ministry of Health) (MISAU). In support of the USAID Forward principles, CHASS emphasizes technical assistance (TA) to host government and local organizations to enhance local ownership of the national HIV/AIDS response.

In line with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 3.0, CHASS uses a data-driven approach that strategically targets geographic areas and populations to achieve the most impact for investments.

This approach aims to close existing coverage gaps and increase access by saturating services in districts and communities where HIV prevalence and unmet need are high. To this end, CHASS provides differentiated packages of support (i.e., scale-up, sustained transition/central support) to HFs and prioritizes scale-up in districts and HFs that have the highest HIV burden, with the goal of reaching saturation levels (Figure 3). In total, CHASS supports 366 ART sites, 397 prevention of mother-to-child transmission (PMTCT) sites, and 397 HIV testing and counselling (HTC) sites in 56 districts.1 New sites not previously supported by CHASS were added at the request of the relevant direcção provincial da saúde (provincial health directorate) (DPS), in most cases because they are expansion sites in priority districts, but in some cases (e.g., in Machange and Cheringoma Districts in Sofala), because these are districts where access to primary health services is limited due to access to sites. In Tete, some sites (e.g., Bolimo, Gandali, and Mufa Caconda) were added because these are sites where patients from supported sites have been transferred under decentralization efforts.

CHASS has three intermediate results (IRs):

● IR1: Strengthened facility-based HIV services.

● IR2: Strengthened community-based HIV services.

● IR3: Strengthened referral and linkage systems between community and facility-based HIV services.

1 These sites do not include PMTCT sites, all of which do HTC within PMTCT. They include sites that provide either voluntary counseling or testing (VCT) or provider-initiated counseling and testing (PICT).

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Figure 3. Districts and health facilities supported by CHASS, showing level of support for districts and facilities providing ART services, FY17 Q4

The next sections of the report highlight accomplishments by IR, in specific program/technical areas from July to September 2017. The sections state how, in the past quarter, CHASS worked with DPSs and with serviços distritais de saude, mulher, e acção social (district directorates for health, women, and social action services) (SDSMASs) to address obstacles affecting access to and quality of facility-based HIV/AIDS services in the four provinces. In a few cases, semi-annual or annual data are presented as well.

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PROGRESS BY INTERMEDIATE RESULT AND PROGRAM AREA

IR1: STRENGTHEN FACILITY-BASED HIV SERVICES

The ultimate goal of CHASS support is to enable HFs to scale up the provision and improve the quality of integrated health and HIV/AIDS services and meet the standards specified by MISAU and global organizations such as the World Health Organization (WHO). To achieve this, the project supports interventions in a wide range of areas including improving the knowledge and skills of health workers, enhancing the capacities of provincial and district health personnel to effectively supervise and manage HFs, improving space and conditions for quality service delivery, activating more sites for HIV/AIDS services so as to enhance access, improving documentation and reporting at the HF level, and improving supply chain and logistics management to enhance the security of health commodities. Strengthening facility-based services also entails improving linkages and referrals both within the HFs and between health facilities and CBOs or other service providers so as to ensure a continuum of care for PLHIV.

HIV Testing and Counseling The goal of CHASS HTC activities is to ensure that 90 percent of PLHIV in CHASS-supported provinces are diagnosed. This is being pursued through targeting populations and locations that are likely to yield high rates of HIV positivity. The project continues to support multiple approaches including routine opt-out testing (ROOT), PICT, stand-alone VCT, and community HIV testing and counseling (C-HTC) that emphasize index case testing. In FY (FY) 17, the target was to offer HTC to 1,128,442 individuals. To achieve the ambitious FY17 HTC target, CHASS emphasized:

● Prioritizing interventions in population groups likely to yield high rates of HIV positivity (e.g., index case testing, optimizing PICT in high-yield sectors) and focusing on the “right” geographic areas (i.e., high prevalence districts and sites where directly observed therapy for TB is provided).

● Organizing patient flow and improving documentation (e.g., HTC registers) in all HTC sites so as to reduce missed opportunities and enhance data capture.

● Conducting systematic PICT trainings of health care providers at all entry points in the 16 priority sites and high-volume HFs.

● Deploying counselors in high-volume HFs to improve pre- and post-test counseling as well as adherence counseling and support.

In Sofala and Niassa Provinces, CHASS teams continued to monitor implementation of the activities at the sites where re-testing is being piloted. Two joint technical support visits (TSVs) by officers from CHASS and MISAU were made to the two provinces. The team also provided on-the-job training to eight health providers of Mutua HC with a focus on re-testing protocols. During the quarter, 77 persons diagnosed with HIV were retested, and there were no variations in the results. This also gives assurance of the quality of HIV testing services (HTS) being provided in CHASS-supported HFs.

To improve index case testing in HFs, CHASS continued collaboration with I-TECH to develop a system for triggering invitations, serving, tracking, and documenting sexual partners of index clients. After piloting, this system will be fine-tuned and scaled up in other sites in the subsequent quarters.

CHASS teams continued to mentor health care providers on optimal use, proper and immediate documentation, reporting, checking expiration dates of health commodities, and prioritizing use of

T: +258 21241100 │ F: +258 21485499 │ www.fhi360.org those with short shelf lives, forecasting, and filling out request forms. The CHASS HTS/psychosocial support (PSS) team completed developing a training package for the operationalization of the PSS/positive prevention (PP) strategy. This will be rolled out in FY18.

Performance in counseling and testing In Q4 of FY17, CHASS tested 516,798 (Q3 418,722) people for HIV and identified 28,089 (5 percent) as HIV-positive (Table 2). The number of people tested continued to increase this quarter, but positivity decreased from the 7 percent seen throughout the rest of the year, and the number of people diagnosed with HIV remained the same as last quarter. Overall, there was a 23 percent increase in the number of people tested, but this was largely the result of a 45 percent increase in the number of people tested in PICT. (This comparison does not include inpatients.) This was the result of multiple actions: 1) continued support to ensure that patients are not referred to VCT but are tested in other sectors and review of the PICT registers, 2) provision of targets for clinicians and daily monitoring that highlights providers who are not testing an adequate percentage of patients seen, 3) additional refresher workshops on testing (e.g., in Manga Mascarenha, Buzi, Chibabava and Machanga in Sofala), 4) an improved focus on stock management which led to fewer stock outs this quarter, and 5) additional provider training on the criteria for testing to avoid lost opportunities.

Table 2. Testing results by sector in Q1 through Q4, 2017 Sector Quarter 1 Quarter 2 Quarter 3 Quarter 4 tested positive positive positive positive positive tested positive positive tested positive positive

VCT 40,910 13% 5,144 44,814 12% 5,414 43,804 10% 4,507 41,746 9% 3,889

PICT* 175,60

6% 9,972 240,852 7% 16,443 236,34

6% 14,072 343,49

5% 16,474

Case Index 5,622 24% 1,371 6,813 23% 1,566 11,799 20% 2,406 17,146 18% 3,116 Other C-

HTC

9,123 10% 946 8,528 12% 1,031 19,636 12% 2,404 10,517 7% 696

ANC 91,907 4% 3,829 96,829 4% 4,207 97,189 4% 3,934 99,835 3% 3,458

Ped <5** 970 5% 53

TB 3,377 15% 495 2,874 14% 402 3,157 14% 440 3,093 13% 403

Total 351,87

7% 22,926 419,483 7% 29,457 418,72

7% 28,086 516,79

5% 28,089

* In Q3 and Q4, PICT includes tests in maternity and partners tested in antenatal care (ANC) in alignment with MER. It also includes inpatient tests.

**In the past we reported all tests for those under 5, but EID is now reported separately in alignment with MER.

As mentioned above, overall testing yield declined this quarter with decreases in all sectors (Figure 4). In terms of the three main modalities of testing, yield remained greatest in C-HTC index case testing, but fewer people were identified through C-HTC because the number of people tested was relatively small (Table 3). However, the percent of all positives identified via this modality increased from 6 to 10 percent because the number of patients tested via index case testing increased. Over the past two quarters, index case testing has contributed just 3 percent of the number of people tested, but it has contributed 8 percent of all diagnoses. The largest number of PLHIV were identified via PICT, but the low yield here highlights the need for more focused testing within PICT. Finally, the declining yield in VCT units is likely the result of fewer patients being referred to VCT units—something CHASS has been encouraging.

Figure 4. HIV positivity yield by sector and quarter, over the past year

Table 3. Yield and contribution to cases identified by modality, FY17 Q4 and year to date Q4 Q2 to Q4 combined*

Yield (% positive)

% of positives identified via this modality # tested

% tested in this modality Yield (% positive)

% of positives identified via this modality # tested

% tested in this modality

VCT 9% 16% 41,746 10% 16% 19% 130,364 13%

PICT 5% 68% 99,835 83% 10% 65% 820,687 80%

Case Index C-HTC 18% 13% 17,146 4% 20% 10% 35,758 3% Other C-HTC 7% 3% 10,517 3% 11% 6% 38,681 4% *These data have not been combined with Q1 data because the high level of misclassification in Q1 makes it impossible to disaggregate index case and other community testing.

The drop in positivity rates in PICT suggests that the efforts to increase coverage in testing are not resulting in the desired increase in case identification. The strategy needs to be revisited to determine how best to proceed in order to identify more new cases.

In terms optimizing PICT, based on sites reporting disaggregated data, both Consulta de Medicina and Banco de Sangue had higher positivity than other sectors (Table 4) when compared with Q3. This suggests a continued focus on improving testing coverage at these entry points, although there are few sites reporting disaggregated data from these points. Yield in triage, which was expected to be higher based on earlier analysis with more limited data, remained at 5 percent this quarter, with 38 additional sites reporting disaggregated data from such units. With a large number of sites and a high volume of patients, these data suggest that increasing coverage in triage may not be as high priority as initially indicated. Please note that the number of sectors reported is based on the number of sites where disaggregated data are collected that have these sectors. For example, only large, central facilities have Blood banks. CHASS aims to report disaggregated data for all DSD sites by the end of FY18.

Table 4. Summary of testing by sector in sites with disaggregated data, FY17 Q4 Sector # of HF with disaggregated data # Tested # Positive %

Positive Comment [EO10]: Added above. Please also see the DATIM narrative where we discuss coverage in more detail.

Comment [9]: For documentation purposes, it would be good to offer a simple explanation for the variation in sector-specific reporting, as well as plans for expanding, as appropriate, this more detailed level of data capture. It is difficult to assess how representative these data are, since it is not clear how the sites were chosen.

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Banco de Sanuge 6 226 32 14% Consulta de Medicina 13 572 48 8% Enfermaria 28 3,211 140 4% Laboratorio 4 291 9 3%

SAAJ 24 7,616 144 2%

Triagem 238 66,569 3,303 5% Banco de Soccoro 27 3,141 107 3%

Variation by geographic area

More tests were conducted in Manica than any other province, but positivity there was 5 percent (roughly the same as in Niassa and Tete). Positivity in Sofala was expectedly higher than in the other provinces, at 7 percent overall, and the percent of tests that were Case Index (CI) was also higher, at 5 percent (versus 2-3 percent in the other provinces). As expected, high-priority districts, particularly the provincial capitals, tested the most people and had relatively high yield. However, some districts testing many people (e.g., Manica and Sussendenga) had relatively low yield, suggesting that they may benefit from more targeted testing efforts and increases in index case testing. (Just 2 percent of those tested in Manica and 1 percent of those tested in Sussendenga were tested via index case testing.)

CHASS has conducted a district-level and site-level analysis of HTC data that is not presented here. These results are being used to identify high- and low-performing areas in order to target TA in Q4, and are available on request.

Performance against HTC targets

CHASS was above target for HTC overall, surpassing the targets in all sectors except VCT (Figure 5). The comparison to the pediatric target is not accurate, as the target was for all under 5s, and the way in which we have been asked to report these data only includes rapid tests for children 9-11 months in consulta da criança em risco (consultation for children at high risk) (CCR). Given that the PEPFAR targets are based on modeling of the number of people who are anticipated to be HIV-positive and the number who do not yet know their status, overall these results suggest that CHASS is testing a sufficient number of people to ensure that 90 percent of PLHIV know their status. With regard to VCT, which is a voluntary service, CHASS has consistently been below target in this area but is continuing to work to create demand for services through both passive referrals of partners of people diagnosed as HIV-positive and demand-creation strategies in communities including radio programs, dialogues, theater, films/discussion, and health education sessions in various sites including within village savings and loan (VSL) clubs. Demand creation has decreased in intensity, because CHASS is focusing on visits and buscas to contribute to retention levels, although work continues with radio programming and health education sessions in HFs, mother-to-mother (M2M) groups, and men-to-men groups and within VSL clubs. In FY18, CHASS will give specialized training to a group of “gender and communication activists” to strengthen demand creation, and we hope this will contribute to increased use of VCT services.

Comment [11]: Manica has more than 63% of all the testing targets, so this is not surprising.

The question that is not adequately explained in this APR narrative is whether CHASS has invested proportionally in Manica (e.g. staffing, etc.) to adequately account for these higher testing targets. What actions have been taken to address chronic under-performance on HTS_POS in Manica?

Comment [ST12]: Yes, to a great extent, CHASS invested proportionately more resources in Manica than any other province in FY 17. For example, out of around 150 locum staff that we engaged and seconded to HFs/SDSMAS to address HRH gaps, 56 are for Manica province. CHASS constituted a Manica taskforce comprised of tech staff from the center and other provinces to support the provincial team in developing, testing and scaling up strategies to spur performance across different indicators.

Emphasis has been put on discussing HTS data with HFs and CBOs as a way of making them appreciate the need to focus resources on population groups and locations likely to yield more positives as well as optimizing opportunities for HIV case identification.

This messaging is woven in PITC and index case trainings and TSVs. Also, CHASS is now pooling pharmacy in all discussions and training related to targeting HTS services. Pharmacists will be helping to match RTKs consumption data with test results to determine service units where RTKs are being “wasted”. These efforts will continue in FY 18.

Figure 5. Performance against target in HTC, by sector, FY17 Q4

Again this quarter, at the provincial level, Nissa, Sofala, and Tete were generally above target. For Sofala, this shows maintenance of their improved performance in Q3 (Table 5). This analysis again highlights the shortfalls in Manica, particularly in index case testing but also in VCT and TB, which are the three highest yield testing modalities. And again this quarter, these results highlight that with the exception of Manica, all provinces are vastly exceeding the targets for PICT and could improve their focus on higher-risk patients in order to improve yield. The comparison with direct service delivery (DSD) targets reinforces the need to better focus efforts in Manica on these key districts and sites.

Table 5. Performance against target by province and testing modality, FY17 Q4 All sites DSD only Provinc e VCT PICT CI ANC TB* VCT PICT CI ANC TB

CHASS 75% 188% 102% 119% 95% 69% 163% 102% 94% 126%

Manica 52% 125% 40% 106% 95% 48% 105% 40% 97% 83% Niassa 178% 425% 263% 185% 89% 236% 393% 263% 104% 154% Sofala 96% 260% 121% 110% 87% 154% 338% 121% 85% 186% Tete 106% 256% 202% 113% 115% 93% 530% 202% 96% 214%

* The targets for newly tested individuals in the TB sector underestimate the number of people who require a test. For example, in DSD sites, only 28 percent of all patients with a result in the register were targeted for a new test, whereas our data suggest that about half of all new TB patients will not know their status.

Analysis at the district level shows that among the 10 districts with the highest targets for numbers tested, only four achieved the target (Table 6). Additional attention will be given to the remaining districts on this list (i.e., Gondola, Macate, Changara, Dondo, Mossurize, Angonia), although the targets for Gondola and Macate seem to be too high given that they are greater than the population of these districts.

Table 6. Performance against target in 10 districts with largest targets, FY17 Q4 Province District # tested % positive Annual target % of target in Q4

Estimated population in

2017* Manica Gondola 20,363 5% 183,058 44% 182,78

Manica Macate 14,321 5% 156,067 37% 119,902 Manica Manica 27,593 4% 116,572 95% 223,836

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Manica Cidade de de Chimoio 27,246 10% 100,072 109% 335,049 Manica Sussundenga 23,246 3% 83,144 112% 174,011 Tete Changara 3,912 2% 81,538 19% 211,120 Sofala Dondo 13,744 14% 70,526 78% 180,905 Sofala Cidade de Da Beira 34,043 12% 67,223 203% 463,442 Manica Mossurize 12,543 4% 64,548 78% 300,187 Tete Angonia 3,914 2% 57,553 27% 401,505

* Source: Instituto Nacional de Estatística. 2010. Projecções Anuais da População Total, Urbana e Rural 2007–2040.

Please see the table below, with data pulled from DATIM. Please confirm if these are genuine errors, or explain what accounts for the differences between the Q4 testing difference in the APR, as compared with the data in DATIM, for these Districts in Manica Province

Challenges related to HTC Work with Johns Hopkins University (JHU) and MISAU to intensify demand creation and stigma reduction activities so as to enhance disclosure, male HIV testing, and index case HIV testing.

Key HTC activities for the next quarter

● Make presentation of HTS performance during quarterly review meetings at provincial levels and discuss with all stakeholders strategies for addressing the gaps.

● Disseminate the FY18 HTS work plan and elaborate on strategies needed to enable CHASS to achieve its FY18 HTS targets.

● Continue mentoring CBOs to optimize rapid test kits (RTKs) through targeted HTC, especially index case testing.

Care and Treatment The focus of CHASS care and treatment interventions is to ensure that at least 90 percent of all people diagnosed with HIV are enrolled in care, 90 percent of those eligible are initiated on ART, 80 percent of them are retained in care at 12 months, and 90 percent of PLHIV on ART achieve viral load suppression.

Comment [EO13]: I think there are two issues here:

First, when I run the data in DATIM, I don’t get the same numbers that you have below (for Manica, I only see 28,427 in DATIM, not almost 36,000). In addition, I note small differences between the totals in DATIM and the sum of the different types of testing in DATIM which may need revision next week. For this review, I used the same approach as that used by the SI team in DC. It would be good to clarify with them because DATIM is not transparent and depending on how you run the tables, you get different numbers. We have no guide as to what is the “correct” way to run the numbers in DATIM except for the SI tables used for data review.

This is the first time we have done this analysis and I ran the table in the report using our data files at is a more efficient process. It looks like there is some issue with district assignments that we will review and correct following the final round of corrections in DATIM next week.

Furthermore, because some small adjustments were made in DATIM at the last minute, we may have small discrepancies that are not reflected here as the changes were made simultaneous to this reporting.

These small changes should not affect the overall picture of what is happening and will be reflected when we rerun the data once it is finalized.

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To achieve this, CHASS is using three major strategies: 1) strengthening the capacity of ART sites to provide comprehensive and quality ART services (including adherence counseling, PSS, and patient literacy to enhance enrollment in care, initiation on ART, and retention); 2) improving linkages between HTC (e.g., with “escorted referral” from HTC to ART service points), care, and treatment to reduce leakages and minimize missed opportunities; and 3) improving patient monitoring and follow-up. During the quarter, significant efforts were invested to achieve the above as follows.

Improving linkages between HTC and ART service delivery points: CHASS continued to pursue its ambitious target of exponentially increasing the number of PLHIV newly initiated on ART. To achieve this, CHASS continued to intensify HIV case identification; ensure that all newly diagnosed PLHIV who are eligible for ART don’t get lost between HTC and ART service delivery points; and identify eligible PLHIV from pre-ART registers and ensure that they are initiated on ART. Specific actions taken included

1) targeting HTS to populations likely to yield more HIV-positive cases, 2) aggressively managing cases of newly diagnosed PLHIV using case managers for escorted referrals from HTC to consultation, 3) opening clinical files for persons testing HIV-positive at places of diagnosis, 4) promoting same-day consultation for all persons testing HIV-positive, and 5) reviewing pre-ART folders for PLHIV eligible for ART and triggering active tracing and ART initiation. CHASS zonal teams supported health care workers in preparing lists of Pre-ART patients eligible for ART initiation for active tracing. As achieving these targets requires concerted efforts, CHASS engaged HF clinical management committees in scale-up and high-volume ART sites in analyzing their HF-specific HIV/AIDS cascades to identify leakages from HIV diagnosis to initiation on ART and offer solutions. In most of the urban high-volume sites, HF management has allowed provision of HIV/AIDS services after working hours, including weekends, to provide HIV services just like they provide emergency services. These efforts will be continued and expanded to more sites in the next FY.

Increasing numbers of PLHIV initiated on ART: To reach the target of having 90 percent of PLHIV eligible initiated on ART, CHASS zonal teams continued to support health care workers in Test and Start (T&S) sites to ensure that all persons diagnosed HIV-positive are initiated on ART within 15 days.