Improving Technical Efficiencies Reaching the First 90 through

Improving Technical Efficiencies: Reaching the First 90 through Community Index & Sexual Network HIV Testing in Zimbabwe. A Muchedzi, N Mahachi, T Moga, T Tafuma, P Mawora, D Harbick, T Nyagura, K Reichert 24 th July 2018

Presentation Outline • Background – Zimbabwe HIV context – Progress towards 90 -90 -90 • Description – FHI 360 Zimbabwe HIV Care and Treatment (ZHCT) Project – FHI 360 Community Index HIV Testing Approach – Sexual Network Testing • Lessons Learned • Conclusion 2

Introduction: Zimbabwe HIV Country Context • Zimbabwe is in Southern Africa • Population: 13 Million (2012) • HIV Prevalence(15 -49): 14%* • HIV Incidence: 0. 48 in 2016 • Total PLHIV: 1. 3 Million* • PLHIV on ART: 1, 029, 719* * National HIV Estimates 2017

Zimbabwe’s Progress Towards 90 -90 -90 100 90 80 70 60 50 40 30 20 10 0 68 76 74 86 87 87 Diagnosed On Treatment Males Females 84 84 86 Virally Suppressed Total • Innovative approaches required for last mile • FHI 360 Zimbabwe HIV Care and Treatment (ZHCT) Project is responding with Community Index HIV and Sexual Network Testing 4

Zimbabwe HIV Care and Treatment (ZHCT) Project • Eight rural districts • Goal: To Increase access and availability of comprehensive HIV care and treatment services through community based interventions • Project compliments Ministry of Health efforts – Towards 90 -90 -90 – Ending AIDS by 2030 5

FHI 360 Community Index Testing Approach • HIV testing – sexual partners and children of index cases – Trained nurse at community level • FHI 360 strengthened community health system District Team Leaders (8) Trained Nurses (~ 40) Community Cadres (120) 6

FHI 360 Community Index Testing Process Community HTS initiatives 7

Nurse Tester Activities at the Household • HIV Testing and counselling • Integrated health symptom screening • Hypertension, Diabetes Mellitus, Malnutrition • Health education on HIV and health topics • ART Adherence counselling • Referral to health facilities for ART initiation 8

Successful Sexual Network Testing: The Case of Tinotenda • • SNT Process Nurses trained to explore SNT Consent to explore SN Case of Tinotenda 9

Summary of Tinotenda: Best Case of Sexual Network Testing Tinotenda • • 7 HIV+ identified (58% Yield) 7 initiated on ART 4 HIV – 1 Not tested for HIV • counselling in progress • Ages: 2 yrs - 50 yrs ~ 4 weeks ~ 230 km covered

Lessons Learned: FHI 360 Project Data Oct 2016 to Sep 2017 14, 818 Index cases identified 22, 147 Tested for HIV 330 Health Facilities 8, 367 Positive 38% Yield Rate 5, 771 Initiated on ART 69% Initiation Rate By Jun 18 Initiation Rate = 89%

Age/Sex disaggregation of People Reached Oct 2016 to Sep 2017 1 -4 • Males tested for HIV: 11, 754 (48%) • Adult men (>15 yrs): 10, 883 (93%) • Adult men identified as HIV+: 3, 705 (34%) 5 -9 10 -14 15 -19 20 -24 25 -49 50+ Female Male 12

Efficiency of Community Index HIV Testing with Sexual Network Testing: Apr 2016—Sep 2017 12, 000 2500 10, 000 2000 8, 000 1500 6, 000 1000 4, 000 500 2, 000 0 No. HIV Positive Persons No. Persons Tested for HIV Sexual network testing introduced 0 Apr-Jun 2016 Jul-Sep 2016 Oct-Dec Jan-Mar 2017 Quarters Tested HIV+ Apr-Jun 2017 Jul-Sep 2017 One HIV positive person identified for every 1. 8 index cases

High Yield Achieved on the FHI 360 ZHCT Project: Apr 2016—Sep 2017 12, 000 42% 39% 10, 000 50% 39% 33% 8, 000 30% 6, 000 16% 4, 000 2, 000 40% 20% 6% Yield No. of Persons Tested for HIV Sexual network testing introduced 10% 0 0% Apr-Jun 2016 Jul-Sep 2016 Oct-Dec Jan-Mar 2017 Quarters Tested HIV+ Apr-Jun 2017 Jul-Sep 2017 • Ave yield 38% with SNT Yield Rate • Yield in sexual partners 44%

Conclusions • Efficient – increased number of HIV+ persons identified • Achieves high and sustained yield • Reaching key subpopulations, – including men, – would not ordinarily access testing using traditional HTS 15

Next Steps • Expand the approach • Integrate HIV Self. Testing (HIVST) • PREP to high risk populations • Scale up Community ART initiation • Conduct cost analysis 16

Acknowledgements • • • PEPFAR/USAID Ministry of Health and Child Care ZHCT Project Beneficiaries ZHCT Project Staff AIDS 2018.

Contact details: Auxilia Muchedzi- ZHCT Project Deputy Chief of Party Email: amuchedzi@fhi 360. org www. fhi 360. org

BACK POCKET SLIDES 19

ZHCT Cascade Oct 2016 -Sep 2017 48% (11, 754/24, 601) were males, with a yield rate of 33% (3, 853/11, 754). 20

FHI 360 Community Index HIV Testing Program Quality Assurance Community Program implementation is guided by • SOPs • Job Aides • FHI 360 pioneered the development of • Community M&E system and tools • Community HIV testing quality assurance system 21

FHI 360/ZHCT HTS Cascade Oct 2016 to Sep 2017 3. 4% of clients tested were retesters. These were removed from the data reported here Av. 2 contact per index case followed up Yield rate: sexual partners (44%), children 17%, 22

Proportion of clients initiated on ART Cohort analysis showing time to ART initiation: Makoni vs Mutasa District, Oct 2017 – May 2018 100% 80% 60% 40% Makoni has more than 50% same day initiation but in 30 days they linked 90% by 30 th day 59% 82% 52% 85% 87% 90% 63% 63% 14 Days 30 >30 29% 20% No community ART 0% initiation in Mutasa 0 7 Makoni (Both Facility & Community ART initiation) Community ART initiation: initiating ART at community level through collaborating with MOHCC facility based or OPHID DSD nurses 23