session 7: implementation solutions and approaches to ... · inhambane vilankulo 1,874 12,428 15%...

Session 7: Implementation Solutions and

Approaches to Reach Epidemic Control among Adult Men

2

Strategic Approaches to Reduce HIV Morbidity and Mortality Among Men

Setting the Scene

HIV Care and Treatment Cascade for Men

Ministry Male Engagement Strategy

Preventing New Infections Among Adolescents & Young Men

VMMC

Increasing ART Coverage Among Men

Strengthening Case Identification

Improving Treatment Initiation

Enhanced Support for Adherence & Retention

3

Men as Proportion of Total Persons on Treatment in Mozambique

In 2014, large-scale retrospective evaluation showed a significant decrease in the proportion of newly enrolled on treatment that were men between 2004 and 2013

2004 2013

0.3% 22%

57% 51%

45% 22%

(Auld et all, 2014)

4

Men Continue to Lag Behind Women in Treatment Cascade Achievements

PEPFAR/MER Data: DevResults (2015 – 2016)/DATIM (2017-2018)

5

Overall ART Coverage is also Lower Among Men than Women In all Provinces

Largest gaps in coverage are in Gaza and Inhambane, locations with high rates of migrant work to S. Africa PLHIV: IMASIDA 2015, Census 2017, Spectrum V5.6;

TX_Curr: PEPFAR/MER (DATIM)

CaboDelgado

Gaza Inhambane Manica MaputoCidade

MaputoProvíncia

Nampula Niassa Sofala Tete Zambézia

Female Coverage 34% 67% 51% 63% 120% 38% 44% 33% 53% 71% 42%

Male Coverage 22% 39% 24% 44% 88% 22% 32% 20% 33% 52% 25%

0%

20%

40%

60%

80%

100%

120%

140%

Co

vera

ge

National Coverage among Men: 33%

National Coverage among Women: 52%

6

Highest Unmet Need for Men found in Zambezia and Maputo Province

PLHIV: IMASIDA 2015, Census 2017, Spectrum V5.6; TX_Curr: PEPFAR/MER (DATIM)

22%

39%

24%

44%

88%

22%

32%

20%

33%

52%

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

CaboDelgado

Gaza Inhambane Manica MaputoCidade

MaputoProvíncia

Nampula Niassa Sofala Tete Zambézia

Co

vera

ge

# o

f P

LHIV

Number of Men on Treatment, Unmet Need, and Coverage by Province, FY17

TX_CURR Unmet Need Coverage

7

Ministry and Civil Society Working Together To Improve Engagement of Males in Treatment

November 2016

Joint stakeholder meeting to understand

successes and challenges in each

province

March 2017

Male engagement TWG started to

develop comprehensive

strategy to improving male engagement

December 2017

National stakeholder meeting to review Male Engagement

Strategy and incorporate best

practices

March 2018

National launch of Male Engagement Strategy (at HIV Program Annual

Meeting)

June-Dec 2018

Roll-out of strategy to priority districts

National Male Engagement Strategy

8

Core Components of MISAU Male Engagement Package

Promotion of friendly services for men in health facilities and in the workplace

Promotion of social norms that may facilitate the use of health services

Promotion of engagement of men as a partner in the care of their wives/children (family care approach)

Promotion of communication and advocacy to increase knowledge and importance of the use of health services by men

Strengthening monitoring and evaluation of the impact of male engagement interventions on health care and community

9

Targeting Male Engagement Strategy to Areas of Highest Need

50% of Unmet Need for Men is Found in 20 Districts

Targets for TX_NEW are most aggressive in these 20 districts

Province District Name

TX_CURR

(FY17)

PLHIV

(FY17)

ART

Coverage

Unmet

Need

% of Unmet

Need

Maputo Província Cidade Da Matola 14,503 90,122 16% 75,619 13%

Sofala Cidade Da Beira 9,964 37,943 26% 27,979 5%

Zambézia Cidade De Quelimane 8,833 27,951 32% 19,118 3%

Manica Cidade De Chimoio 7,511 19,516 38% 12,005 2%

Nampula Cidade De Nampula 6,380 17,958 36% 11,578 2%

Zambézia Nicoadala 2,723 14,218 19% 11,495 2%

Cabo Delgado Mueda 2,163 13,345 16% 11,182 2%

Maputo Província Marracuene 3,321 14,393 23% 11,072 2%

Inhambane Vilankulo 1,874 12,428 15% 10,554 2%

Maputo Província Boane 3,313 13,846 24% 10,533 2%

Zambézia Mocuba 4,098 14,311 29% 10,213 2%

Zambézia Namacurra 3,142 13,111 24% 9,969 2%

Zambézia Pebane 3,476 13,229 26% 9,753 2%

Maputo Cidade Kamubukwana 4,427 13,343 33% 8,916 2%

Gaza Chokwe 7,722 16,513 47% 8,791 2%

Gaza Bilene 3,579 11,012 32% 7,433 1%

Gaza Cidade De Xai-Xai 4,651 11,856 39% 7,205 1%

Zambézia Milange 2,589 9,636 27% 7,047 1%

Zambézia Maganja Da Costa 1,966 8,956 22% 6,990 1%

Cabo Delgado Muidumbe 1,321 7,861 17% 6,540 1%

10


50% of Unmet Need for Men is Found in 20 Districts

Province District Name

TX_CURR

(FY17)

PLHIV

(FY17)

ART

Coverage

Unmet

Need

% of Unmet

Need

Maputo Província Cidade Da Matola 14,503 90,122 16% 75,619 13%

Sofala Cidade Da Beira 9,964 37,943 26% 27,979 5%

Zambézia Cidade De Quelimane 8,833 27,951 32% 19,118 3%

Manica Cidade De Chimoio 7,511 19,516 38% 12,005 2%

Nampula Cidade De Nampula 6,380 17,958 36% 11,578 2%

Zambézia Nicoadala 2,723 14,218 19% 11,495 2%

Cabo Delgado Mueda 2,163 13,345 16% 11,182 2%

Maputo Província Marracuene 3,321 14,393 23% 11,072 2%

Inhambane Vilankulo 1,874 12,428 15% 10,554 2%

Maputo Província Boane 3,313 13,846 24% 10,533 2%

Zambézia Mocuba 4,098 14,311 29% 10,213 2%

Zambézia Namacurra 3,142 13,111 24% 9,969 2%

Zambézia Pebane 3,476 13,229 26% 9,753 2%

Maputo Cidade Kamubukwana 4,427 13,343 33% 8,916 2%

Gaza Chokwe 7,722 16,513 47% 8,791 2%

Gaza Bilene 3,579 11,012 32% 7,433 1%

Gaza Cidade De Xai-Xai 4,651 11,856 39% 7,205 1%

Zambézia Milange 2,589 9,636 27% 7,047 1%

Zambézia Maganja Da Costa 1,966 8,956 22% 6,990 1%

Cabo Delgado Muidumbe 1,321 7,861 17% 6,540 1%

Highest Burden Districts Included

Among 59 Districts

Prioritized for Male

Engagement in FY18-FY19

11

ART Coverage by Age Among Males

Adult men (Age 25-49) make up 69% of the Unmet Need ART Coverage is lowest in adolescent men (Age 15-24)

Data source: Spectrum v5.63, FY17 TX_CURR Program results are imputed for sites missing age bands (non-EPTS sites)

29%

37% 40%

23% 19%

34%

58%

0%

10%

20%

30%

40%

50%

60%

70%

-

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

<1 1-9 10-14 15-19 20-24 25-49 50+

Co

vera

ge

PLH

IV

Current on Treatment, Unmet Need, and Coverage by Age among Males, FY17

TX_CURR Unmet Need Coverage %

12

Strategic Approaches to Reduce HIV Morbidity and Mortality Among Men

Adolescent Men (Focus: Age 15-24)

Preventing New Infections:

- Continued VMMC Scale-up

- Community Outreach

- Condoms

Adult Men (Focus: Age 25-49)

Improving ART Coverage:

- Early Case Detection

- Improving Linkage and Treatment Initiation

- Strengthening Retention and Adherence

Implementation Solutions and Approaches to Prevent Infections among Adult Men

- VMMC -

14

Impact of PEPFAR-Supported VMMC Program Notable in Surveillance Data Coverage

9.20%

20.10%

47.50%

68.60% 71.10%

23.41%

31.00%

39.59%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

2009 2010 2011 2012 2013 2014 2015

% M

en a

ged

15

-49

wh

o a

re c

ircu

mci

sed

Data Collection Year

Zambezia Tete Manica

Sofala Gaza Maputo

Maputo City Weighted Average

INSIDA DHS IMASIDA

Start of PEPFAR-Supported VMMC

Program

PROJECT SOAR

15

COP Planning Decision Tree: VMMC Coverage

Problem Diagnosis

Strategic Objective

Approach

Many districts <80%

coverage among 20-29 year old men

Problem Statement/Indicator

New strategies

needed for districts with

higher coverage and lower growth

Monitoring and Partner Management

Scale up most effective program elements

16

Encouraging Results From the Caia Campaign

November/December 2017

District Health facility Type of site VMMCs Completed, November - December 2016

VMMCs Completed, November - December 2017

Caia

CS Caia Fixed 540 605

CS Murraca Mobile N/A 196

CS Sena Temporary N/A 375

Total 540 1176

120% Increase in circumcisions compared to prior year, 20% of district annual target

achieved in 5 weeks

• Future campaigns to have: • Sites better prepared to host upcoming

campaigns • Stronger involvement of local leadership

in demand creation

17

Scale up plan for campaigns

12 campaigns in 24 districts anticipated to make up 21% of annual CDC

target

1176

10000

23288 23112

0

5000

10000

15000

20000

25000

Q1 Q2 Q3 Q4

COP17 Quarters

#of MC

18


Problem Diagnosis

Strategic Objective

Approach

Many districts <80%


Campaigns


New strategies




# of campaigns & # of temp. sites/quarter


19


Problem Diagnosis

Strategic Objective

Approach

Many districts <80%


Campaigns


New strategies






Implement additional demand creation

• Non-coercive incentives

• Grassroots soccer

• Targeting informal markets

• Active collaboration with

civil society.

• Recruitment of additional

CBOs

20

COP18 VMMC Targets Follow Trend of Aggressive Growth

86% of annual target. With more aggressive interventions, target

achievable

21

Targeting for VMMC Saturation

*Provincial coverage estimates based on SOAR data using weighted average of districts with VMMC targets (non-targeted districts excluded)

Province FY16

Achievement FY17

Achievement COP17 Target COP18 Target

Maputo City 79 86 87

92

Maputo Province 65 71 77

85

Gaza 42 56 76

84

Manica 17 31 49

66

Sofala 38 58 72

89

Tete 9 31 53 74

Zambezia 52 65 77 86

22

Trend of the VMMC National Program by Province

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2010 2011 2012 2013 2014 2015 2016 2017 COP17Target

COP18Target

An

nu

al V

MM

Cs

Year

Gaza

Manica

Maputo Cidade

Maputo Provincia

Sofala

Tete

Zambezia

DOD

23

JHPIEGO Performance Lags Behind Other Partners

Province Partner FY17 Achievement

% FY17 Target Achieved

FY18 Q1 Achievement

FY18 Seasonal Estimate

FY18 Estimated Achievement

Military Jhpiego 24,289 83% 5,397 24,238 88%

Gaza Jhpiego 26,745 91% 5,552 24,934 61%

Maputo City Jhpiego 12,338 65% 1,627 7,307 474%

Manica JSI/AIDSFree 51,482 112% 16,440 73,832 107%

Maputo Province

Jhpiego 15,383 73% 3,225 14,483 60%

Sofala Jhpiego 44,016 43% 9,707 43,594 73%

Tete JSI/AIDSFree 49,154 100% 12,065 54,184 106%

Zambezia ICAP 47,255 86% 11,668 52,401 109%

Zambezia Jhpiego 43,488 57% 12,013 53,950 66%

24

High Saturation in JHPIEGO-Supported Provinces

*Provincial coverage estimates based on SOAR data using weighted average of districts with VMMC targets (non-targeted districts excluded)

Province Partner FY16

Achievement FY17

Achievement COP17 Target COP18 Target

Maputo City JHPIEGO 79 86 87 92

Maputo Province JHPIEGO 65 71 77 85

Gaza JHPIEGO 42 56 76 84

Manica AIDS FREE 17 31 49 66

Sofala JHPIEGO 38 58 72 89

Tete AIDS FREE 9 31 53 74

Zambezia JHPIEGO/ICAP 52 65 77 86

25

JHPIEGO Corrective Action Plan

• Scale up of:

• VMMC campaigns

• Temporary sites (Increased from 20 to 66)

• Public-private partnerships to cover large companies and informal markets

• Demand creation

• Incorporation of selected practices from other partners

• Single VMMC commodity partner

• Support from central demand creation partner

• Site optimization tool

• Enhanced monitoring

• Target redistribution

26

JHPIEGO Corrective Action Plan Tool

Weekly Targets

Performance towards target

District Capacity

27

JHPIEGO Corrective Action Plan Tool

Action Plan Strategies by

district

Targets by

Strategy

Timeline including

planning and implementation

28

Target Redistribution from CDC JHPIEGO to ICAP

• ICAP to cover 6 additional underperforming districts

• Transition starts immediately

• Joint work plan in preparation: CDC, ICAP, Jhpiego and MOH

Partner COP17 Total targets COP18 Total targets

AIDSFREE 120,470 128,549

ICAP 51,368 70,966

JHPIEGO 204,924 197,129

JHPIEGO FADM 27,527 34,343

Grand Total 404,289 430,986

29


Problem Diagnosis

Strategic Objective

Approach

Many districts <80%


Campaigns


New strategies






Implement additional demand creation

Enhanced monitoring,

# of MCs/Week by district

Target redistribution

- Incentives - Grassroots

Soccer - Community DC

Improving Early Case Identification Among Men

31

Growth in case detection among

males during FY17 was due to

programmatic shifts that included strengthening PITC

in high-yield sectors and

expansion of high-yield community-based modalities

such as index case testing.

0

2000

4000

6000

8000

10000

12000

CHASS ICAP ARIEL CCS EGPAF FGH JHPIEGO

Male positive HTC results by partner FY17 Q1-Q4

FY17 Q1

FY17 Q2

FY17 Q3

FY17 Q4

Most Partners Show Increases in Identification of Positive Men

32

Decision Tree: Case Identification for Adult Men

Problem Diagnosis Strategic Objective

Approach

Low case identification

for men

Increase case identification of

HIV+ men


Men not seeking health care @

facilities

Providers not screening men

sufficiently for HIV risk within high-

yield sectors

Providers not following-up

sufficiently with women for index case or partner

testing


33

Key Policy Achievements for Continued Performance in HTS

• Leadership from MOH for expansion of index case testing as effective intervention.

• Design of new HTS registers to document all eligible sexual partners and biological children of PLHIV for subsequent follow-up.

Index Case Testing

• Development of National Male Engagement Strategy to promote male accompaniment and male testing during first ANC and to guide targeted community-based testing efforts.

ANC Partner Testing

• Development of National Guidelines for Differentiated Service Delivery Models for HTS to prioritize efficient case identification in high-yield sectors.

PICT

All included as core components in the National Strategy for Male Engagement

34



Approach


for men


HIV+ men



facilities



yield sectors



testing

Index coverage proxy by district; MER & New HTC

Registers


Scale-up Community-Based Index Case Testing

35

5.0%

17.3%

28.9%

23.4%

2.1% 4.3%

9.0% 9.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

15-19 yrs 20-24 yrs 25-49 yrs 50+ yrs

Mal

e T

est

ing

Yie

ld

Male Yield by Modality and by Age Group, FY17 & FY18 Q1

Yield - Index

Yield TB

Yield Other PITC

Yield Other Comm.

Yield VMMC

Strategic Shift to Community Index Case Testing is Working

Average yield among adult men from index

case testing in FY17 was higher than the target

set (15% overall). In FY19 the program will continue a shift away

from lower-yield community-based testing strategies.

Index case testing yield 3x other community testing yield

36

Setting Index Case Testing Coverage Benchmarks

Benchmark for Index Case Testing coverage used to identify areas for further growth

Coverage proxy:

# Male Adult Index TST conducted

÷ # Female Adult Non-Index POS

= Index Testing

Coverage Proxy

37 PTARGET ASSUMPTIONS MAY NOT BE EXACTLY AS STATED

Targeting Scale-Up of Best Index Case Testing Practices in COP18

Province

FY17 Adult

Index TST

Achieved

FY17 Adult

Index

Yield

FY19 Adult

Index TST

Target

% Increase

Index TST

FY18

Community

Index Case

Testing Partner

FY19 Community

Index Testing

Partner

Cabo Delgado 10,700 4.9% 12,458 16% ARIEL ARIEL

Cidade De Maputo 20,469 28.0% 49,126 140% Jhpiego Jhpiego

Gaza 38,931 9.8% 45,579 17% EGPAF EGPAF

Inhambane 2,073 15.9% 8,199 295% N’weti N’weti

Manica 3,158 29.5% 26,304 733% CHASS CHASS

Maputo 39,161 22.3% 87,740 124% Jhpiego/ARIEL Jhpiego/ARIEL

Nampula 640 25.9% 17,363 2,613% ICAP/Ophavela Jhpiego

Niassa 863 37.0% 7,730 796% CHASS CHASS

Sofala 6,803 37.0% 22,081 225% CHASS CHASS

Tete 3,895 22.4% 8,734 124% CHASS CHASS

Zambezia 8,424 29.5% 59,778 610%

FGH/CHASS/

ICAP/World

Vision

FGH/CHASS/

Jhpiego/World

Vision

Grand Total 135,117 262.2% 345,091 155%

Targets reflects scale up: ratio of index cases to seeds from 0.75 to 1.5

COP18 target assumes improved fidelity, yield of at least 25%

Substitution of lower

performing partners for partner with

demonstrated ability to

implement at scale

38



Approach


for men


HIV+ men



facilities



yield sectors



testing


Registers


Sector-specific testing coverage by site; MER &

New HTC Registers

Optimize Facility-Based Testing (PICT & ANC

Partner Testing)


39

Intervention Package for Effective PITC Optimization

Secure district-

level MOH buy-in

Through regular engagement and joint supervision activities

Reinforce index

contact eligibility screening

Through training on enhanced post-test

counselling and referrals

Provide regular

logistical support for operations

Monitoring of testing coverage and yield

Through facilitated data review sessions

with providers

Set sector-level TST & POS targets

Reinforce accompanied referrals for

initiation

Through regular coaching and observation during follow-up to training activities

Offer need-based clinical

mentorship for quality HTS

Identifying trends and missed

opportunities

• Work closely with District-level MOH leadership to establish clear site and sector-level targets for case identification based on historical yield

• Conduct refresher trainings with providers on HIV testing and accompanied referrals

• Hold regular data review meetings at site level to assess progress against PITC targets

Clinical Partners:

40

Male Congregate Setting Testing Strategy

• Newly funded in FY18

• 4 teams developed methodology in 4 central districts of Zambezia

• Roll-out to total of 16 districts in Zambezia in FY18

• Approach

• Venue mapping

– In Quelimane, fisherman, bicycle taxi drivers, military recruitment center, formal and informal markets

• Community-based testing

• Synergies with other prevention interventions: VMMC referrals, index case testing

Month

HIV+ Men Diagnosed

Men Tested % Yield

Among positives, % first time testers

Dec, 2017 186 1799 10% 82%

Jan, 2018 189 1969 10% 91%

Feb, 2018 254 2720 9% 91%

TOTAL 629 6488 10% 89%

41

# of Men Diagnosed Through Male Congregate Testing Promising

392

222

186

150

46 32

9 6 5 4 3 2 0

50

100

150

200

250

300

350

400

450

Other PICTMale congregateVCT Emergency VMMCCommunity IndexFacility Index TB VMMC Inpatient KP

# D

iagn

ose

d w

ith

HIV

Adult Males Diagnosed with HIV in Quelimane, Zambezia--December, 2017

42



Approach


for men


HIV+ men



facilities



yield sectors



testing


Registers


Sector-specific testing coverage by site; MER &

New HTC Registers

Optimize Facility-Based Testing (PICT & ANC

Partner Testing)


Male Congregate Setting Testing

43

HTC Targeting Increase in Index Case Testing

COP17 COP18

Row Labels Tests Pos Yield Distribution of Pos Tests Pos Yield

Distribution of Pos

Community IC 220,710 32,009 14.5% 8.4% 200,851 50,755 25.3% 13.7%

Mobile 159,732 11,656 7.3% 3.1% 47,658 4,603 9.7% 1.2%

Other Community 43,790 4,398 10.0% 1.2% 0.0%

Facility IC 13,796 1,570 11.4% 0.4% 31,629 10,114 32.0% 2.7%

Inpatient 85,699 18,260 21.3% 4.8% 55,875 7,743 13.9% 2.1%

Emergency 2,631,541 159,681 6.1% 43.0%

VCT 600,577 82,900 13.8% 21.7% 836,030 88,692 10.6% 23.9%

Other PICT 3,197,609 216,270 6.8% 56.7% 667,394 37,456 5.6% 10.1%

TB 39,595 9,420 23.8% 2.5% 99,268 5,025 5.1% 1.4%

VMMC 401,545 4,870 1.2% 1.3% 396,642 7,500 1.9% 2.0%

Total 4763053 381353 8.0% 100.0% 4966888 371569 7.5% 100.0%

Index Case POS Target Doubled,

16.4% of all POS

44

Focusing Targets in Areas of Highest Unmet Need

45% of all testing targets in FY19 are from the 20

districts with the highest unmet need for men

Province District Adult Male POS Maputo Matola 5,661

Sofala Beira 5,547

Manica Chimoio 3,985

Zambezia Quelimane 3,903

Cidade De Maputo Kamavota 3,189

Zambezia Mocuba 2,935

Tete Tete 2,786

Sofala Dondo 2,520

Cidade De Maputo Nlhamankulu 2,512

Gaza Chokwe 2,236

Cidade De Maputo Kampfumu 2,234

Zambezia Pebane 2,175

Zambezia Namacurra 2,001

Zambezia Nicoadala 1,988

Maputo Marracuene 1,982

Cidade De Maputo Kamaxakeni 1,898

Maputo Manhiça 1,880

Manica Manica 1,708

Nampula Moma 1,675

Cidade De Maputo Kamubukwana 1,657

Cabo Delgado Pemba 1,605

Cabo Delgado Mueda 1,500

Sofala Nhamatanda 1,488

Zambezia Maganja Da Costa 1,484

Gaza Chibuto 1,460

Cabo Delgado Muidumbe 1,413

Gaza Xai-Xai 1,402

Case identification efforts among men

in FY19 will continue to focus on districts

with the highest need

Improving Rates of Treatment Initiation Among Men

46

FY18 Q1 Treatment Performance by Partner

IP TX_NEW Q1FY18

TX_NEW FY18 Target

TX_NEW Q1FY18%

Achievement

TX_CURR Q4_FY17

TX_CURR Q1_FY18

TX_CURR FY18 Target

TX_CURR Q1FY18%

Achievement

NET_NEW (Q1FY18

vs Q4FY17)

FY18_ NET_NEW

Target

NET_NEW Q1FY18 %

Achievement

TX_CURR Growth

ICAP 13,337 47,900 28% 131,656 139,872 162,783 86% 8,216 31,127 26% 6%

FGH 11,365 60,268 19% 105,319 96,476 128,273 75% 4,011 35,808 11% 4%

ARIEL 11,996 64,726 19% 169,744 176,571 207,971 85% 6,827 38,227 18% 4%

JHPIEGO (DOD) 713 4,701 15% 11,085 11,522 13,916 83% 437 2,831 15% 4%

EGPAF 8,651 46,764 18% 129,371 133,009 165,985 80% 3,638 36,614 10% 3%

CHASS 22,316 97,731 23% 251,423 268,260 349,741 77% 3,983 85,464 5% 2%

CCS 11,252 53,087 21% 196,910 198,204 233,461 85% 1,294 36,551 4% 1%

Overall New on Treatment, Current on Treatment, Net New, and Growth in Tx_Curr by Partner

47

Most Provinces On Track to Achieve Targets for TX_NEW Target for Men

14% 16%

34%

23%

9%

21% 19%

43%

18%

35%

29%

23%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0

1000

2000

3000

4000

5000

6000

7000

_MilitaryMozambique

Cabo Delgado Cidade DeMaputo

Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia

Male Quarterly New on Treatment Trend (FY17 – FY18) and Target Achievement (FY18 Q1)

FY17 Q1

FY17 Q2

FY17 Q3

FY17 Q4

FY18 Q1

FY18 % Target

Main challenges are in Cabo Delgado, Inhambane, Niassa, and Military sites:

48

Decision Tree: Treatment Initiation Among Men


Approach

Lower rates of treatment initiation

among HIV+ Men



Challenges with case identification

Lower rates of

linkage to treatment

Lack of male-

friendly services

Lower health seeking behavior

among men

Stigma/Cultural Norms

49

Linkage to Treatment Remains Lower among Men than Women in All Provinces

99% 104%

91% 90% 90%

98%

83% 79% 80%

85%

94%

79%

93%

77%

89%

71%

87%

63% 58%

67% 69% 75%

0%

20%

40%

60%

80%

100%

120%

0

2000

4000

6000

8000

10000

12000

CaboDelgado

Gaza Inhambane Manica Maputo Maputo City Nampula Niassa Sofala Tete Zambezia

Linkage Proxy (TX_NEW/HTX_POS), Females vs. Males, FY18 Q1

Linkage to Treatment Highest in Gaza, Manica, and Maputo City

50

Linkage to Treatment Increased in All Provinces in FY18 Q1

70%

75%

59%

76%

70% 75%

60%

53% 56%

61%

74%

68%

79%

93%

77%

89%

71%

87%

63%

58%

67% 69%

75% 75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cabo Delgado Gaza Inhambane Manica Maputo Maputo City Nampula Niassa Sofala Tete Zambezia National

Ration of TX_NEW to HTX_POS by Province, FY17 Q4 and FY18 Q1

FY17 Q4 FY18 Q1

51

Notable Improvements in Linkage to Treatment with Roll-out of T&S

0%

20%

40%

60%

80%

100%

120%

Q1FY17 Q2FY17 Q3FY17 Q4FY17 Q1FY18

Lin

kage

%

Quarterly Male Linkage by Test & Start Phase, Q1FY17 to Q1FY18

Phase 1

Phase 2

Phase 3

Phase 4

Aug 2016 Test & Start

Phase 1

March 2017 Test & Start

Phase 2

Sept 2017 Test & Start

Phase 3

52



Approach


among HIV+ Men

Improve ART uptake among

men Finalize and

implement national tools for linkage

tracking


Complete roll-out of T&S with same-day

clinical appointments and ART initiation <15

days

HTC_Pos (Male):

TX_NEW (male)



Lower rates of


Lack of male-

friendly services


among men


53

National Roll-out of T&S

Aug 2016

Phase 1 T&S

• 14 highest burden districts

• Est. PLHIV: 772,000 (36% of PLHIV)

April 2017

Phase 2 T&S

• 8 high-burden districts


Sept 2017

Phase 3 T&S

• 37 districts


FY18: National Roll-out of T&S

• 96 districts


52% 52%

43% 40%

0%

10%

20%

30%

40%

50%

60%

0

100000

200000

300000

400000

500000

Phase 1 Phase 2 Phase 3 Phase 4

FY17 Unmet Need and ART Coverage by Test and Start Phase

Number on Treatment Unmet Need Coverage

Update on Phase 4: February

2018 Circular

Announcing T&S in all remaining Scale-up Districts

54

63%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Proportion of Newly Enrolled who’s Clinical Appointment was the Same Day as their Diagnosis

a.Sept-Oct 2016 b.Oct-Nov 2016 c.Nov-Dec 2016 d.Dec-Jan 2017 e.Jan-Feb 2017

f.Feb-Mar 2017 g.Mar-Apr 2017 h.Apr-May 2017 i.May-Jun 2017 j.Jun-July 2017

k.Jul-Aug 2017 l.Aug-Sept 2017 m.Sept-Oct 2017 n.Oct-Nov 2017 o.Nov-Dec 2017

*Data from High-volume T&S Phase 1 Sites

Same Day Clinical Appointments and ART initiation within 15 days

• HTC Counselor opens clinical file in testing sector, enrolling patient in HIV care

• Patient escorted to clinical visit

• Receives first pre-ART counseling the day of diagnosis

• Referred for consented follow-up (phone call followed by home visit) if does not return to initiate ART in <15 days

55

HTC daily register: Instructions on how to fill in the clinical linkage page

Linkage monitoring For each patient

diagnosed with HIV, the testing provider records personal data and the patient's clinical follow-up plan on the clinical linkage control page

Revised MISAU HTC Register

56

Linkage Monitoring If a patient does not

reach the clinical services (is not linked within 7 days), the contact information is used to perform the active search.

HTC daily register: Instructions on how to fill in the clinical linkage page

Revised MISAU HTC Register

57

Translating Linkage work into COP18 Targeting Approach

Linkage Assumptions for COP18:

• Assumes 100% of identified positives eligible for treatment

(Test & Start)

• 4% of New on ART will be from persons previously identified

• This is based on the assumption that the final, national roll-out of T&S will be mostly completed prior to the start of COP18

• Assumes 85% linkage of positives into treatment nationally

• Consistent with improved performance trend, after pre-ART enrollments have subsided

58



Approach


among HIV+ Men


men



TX_CURR (male)

Implement male engagement package

to improve service delivery to men


Lower rates of


Lack of male-

friendly services


among men


59

Most Provinces On Track to Achieve Targets for TX_NEW Target for Men

14% 16%

34%

23%

9%

21% 19%

43%

18%

35%

29%

23%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0

1000

2000

3000

4000

5000

6000

7000

_MilitaryMozambique

Cabo Delgado Cidade DeMaputo

Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia

Male Quarterly New on Treatment Trend (FY17 – FY18) and Target Achievement (FY18 Q1)

FY17 Q1

FY17 Q2

FY17 Q3

FY17 Q4

FY18 Q1

FY18 % Target

Notable Increase in Treatment Initiations in Gaza, Sofala, and Zambezia

60

Compiling Best Practices in Reaching Men

61

Male Engagement Strategy Approaches to Improve Treatment Initiation

• Comprehensive disease screening in male outreach programs, and male-focused clinics

• Extended hours in select sites Male-friendly services

• Facilitation of community dialogues (“Men-for-men”), engagement of community & religious leaders to promote changes in social norms

Promoting New Social Norms

• Expansion of family approach including provision of male-focused prevention and family planning messages to couples

Family-based care

• Mobilization of men through male champion & community leaders to improve uptake of services

Communication & Advocacy

• Utilize routine information system indicators disaggregated by gender to monitor impact of strategy on uptake of services by men

Measuring Impact

62


Highest Burden Districts Included

Among 59 Districts

Prioritized for Male

Engagement in FY18-FY19

63



Approach


among HIV+ Men


men Finalize and

implement national tools for linkage

tracking


Complete roll-out of T&S with same-day

clinical appointments and ART initiation <15

days

HTC_Pos (Male):

TX_NEW (male)


TX_CURR (male)

Implement male engagement package

to improve service delivery to men


Lower rates of


Lack of male-

friendly services


among men


Improving Retention and Adherence to Treatment

65

Lower Retention Among Males, Especially Young Males Nationally

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

12

-mo

nth

Ret

enti

on

(%

)

Retention Among All Persons, Adult Men, and Adolescent Men by Province, FY17

Total (all populations) Adult Men Adolescent Men (15 to 24 years)

66

Enhanced Retention Monitoring Shows Only Minimal Improvements

3-month retention remains low at 70% Most patient attrition occurs in the first 3 months of treatment

67

Viral Suppression Appears to Be Lower for Men than Women, FY17 (DISA)

Source: DISA FY17

Routine Suspected Failure Not Specified

Not suppressed

Suppressed Not

suppressed Suppressed

Not suppressed

Suppressed

Males 15+ 8,729 17,327 1,416 1,230 3,259 6,463

34% 66% 54% 46% 34% 66%

Females 15+ 25,637 57,658 2,423 2,008 7,791 19,993

31% 69% 55% 45% 28% 72%

TOTAL 40,279 78,934 4,469 3,414 13,054 28,187

34% 66% 57% 43% 32% 68%

68

Viral Load Suppression For Men Was Around 66% at FY17 (DATIM)

VL suppression rates were

lowest among children and

adolescents and increased with

age

66%

42%

50%

60% 63%

74%

69

Decision Tree: Improving Adherence & Retention among Men

Problem Diagnosis

Strategic Objective

Low retention and VL

suppression among Men

Increase retention

and adherence

among men


Poor health seeking behavior

Health care system not male-friendly

Challenges accessing services

Stigma/cultural norms lead to low patient adherence

Late initiation leads to poorer outcomes

70


Problem Diagnosis

Strategic Objective



Increase retention

and adherence

among men

Differentiated Service Delivery







Improve Psychosocial Services available to Men

Improving Quality of Services

Increased Outreach to Reduce Stigma, Address

Cultural Norms

Community Outreach to Improve Linkage to

Services

MISAU’s Five Pillars for

Improving Adherence &

Retention

71


Problem Diagnosis

Strategic Objective



Increase retention

and adherence

among men









Enhanced Retention Monitoring; DSD

M&E

Approach Monitoring and Partner Management

72

Improving Availability of Patient-Friendly Services

Key Differentiated Service Delivery Approaches in Mozambique

• Community Adherence and Support Groups

• 3-month drug dispensing

• Family approach

• One-stop-shop models (MCH, TB, Adolescents)

• Adherence clubs/Support groups

• Community ART distribution through mobile brigades

73

Uptake of Differentiated Service Delivery Approaches (Dec 2017)

Activity Number of Facilities

Implementing

Test and Start 712

GAACs 475

Family Approach

257

3-Month Drug Dispensing

66

% Uptake from High-Volume Test & Start Sites from 5 partners

74

COP18 Plans to Increase Uptake and Fidelity of DSD Approaches

Dissemination of MISAU tools to improve harmonization and increase uptake of approved approaches

75

Vaccination

Vitamin A

Child Growth

Monitoring

Family Planning

Pre-Natal + Post-

Partum Care

Maternal Health

Community

Mobile

Brigade

ART

New Approaches to Reach Hard-to-Reach Populations

76

Enhanced Quality Improvement Focused on Adherence & Retention

Objectives Activities Anticipated

Impact

1 Improve quality of services in facilities

nationally Expansion of National QI Strategy

Quality and friendly

services can

encourage men to

return to the

facility and be

adherent to

medication

2

Continuous staff capacitation &

mentorship to assure male-friendly

services

Revitalize use of tools for routine

for clinical mentorship

3

Identification of causes for low men

retention and adherence and plan men-

centered corrective interventions

Develop facility-based action plans

using newly incorporated

indicators on retention and VL

4

Provide oversight/support for QI

activities to assure men-centered

interventions are implemented

Joint supervision with MISAU

using standardized approach

77


Problem Diagnosis

Strategic Objective



Increase retention

and adherence

among men







Approach Monitoring and Partner Management



Cultural Norms


Services

Retention and VL suppression indicators

disaggregated by gender and age

78

Integration of Peer Support into National System

APSS Focal Person (Ministry Staff)

HEA

LTH

FA

CIL

ITY

(M

ISA

U/D

PS/

PEP

FAR

)

CO

MM

UN

ITY

SU

PP

OR

T (P

EPFA

R/G

F/C

BO

s)

Support for Linkage, Counseling & Adherence

Support, Phone Calls after Missed Visits

Lay Counselors/ Peer Educators (Clinical partners)

Peer Educators/Activists (Community partners)

Adherence Support, Supportive Home Visits,

Loss-to-Follow-up Tracing,

79

Adherence Support for Targeted Patients

1. All men with identified adherence problems (including defaulters)

2. Viral load > 1000 Copies and/or CD4<200

3. Patients with suspected treatment failure 4. All patients with positive EID results

1. All men initiating ART with high adherence risk (using stratification tool)

2. All PBFW (stratified by risk) 3. All children 0-14 years (stratified by

risk) 4. TB-HIV patients 5. Patients with other chronic severe

clinical conditions and malnutrition

Preventive/Supportive Home Visits

Facility & Community-based Peer

Support

Targeted Home-Based Psychosocial Support

80

Schedule for Targeted Home-Based Psychosocial Support

POPULATION ACTIVITY FOLLOW-UP SCHEDULE

Day 0 (ART start)

15 days

30-45 days

2 3 4 5 6 7 8 9 10 11 12

Adults Newly Initiated on ART

Counselling x x x x x x x

Supportive home visits (If

identified as high risk)

x x x x

FOLLOW UP SCHCEDULE

Adults Stable on ART

Counselling • Continues every 3 months

Adults Not Stable on ART (High VL, Poor

Adherence)

Phone Calls/ Home Visits

• Monthly visits for 3 months to reinforce adherence • Afterwards resume quarterly counseling visits at the health facility

Adults at Risk for LTFU

(Defaulters)

Phone Calls/ Home Visits

• If patient misses appointment receives a phone call within 7 days • If not reached after 3 attempts within 3 days, referred for home visit (active tracing)

• Up to 3 visits within 3 weeks to encourage return to facility

81

Community Activities to Improve Adherence & Retention among Men

Strengthened community support

encouraging men to seek and be retained

on treatment

Improve Treatment Literacy by leveraging

Key Community stakeholders and

structures

Community-level support through GAAC’s, Men and

Saving’s Groups

Improved monitoring of Community Interventions

supporting retention

82


Problem Diagnosis

Strategic Objective



Increase retention

and adherence

among men











Cultural Norms


Services

Enhanced Retention Monitoring; DSD

M&E

Retention and VL suppression indicators

disaggregated by gender and age

Targets & Budget

84

Summary of Targets

General Targeting Approach:

• Aimed to accelerate treatment initiation to achieve 20% higher TX_NEW in COP18 as compared to COP17

• Targeting for highest growth in locations with most unmet need

• Focus on improving retention to achieve 90% retention among new on treatment and 95% retention among those on treatment >12 months

Scale-up Saturation Districts

FY17 Coverage Targeted Growth:

>90% 10% increase per year

71-90% 15% increase per year



Scale-up Aggressive Districts




<20% 50% increase per year

Sustained Districts

10% per year

Attained Districts

5% increase per year

85

Continued Geographic Focus in Areas of Highest Need

354023 409091 480109 528569

507559 699404

913867 1103587

117443

135889

168877

184615

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

2000000

FY17 TX_CURR FY18 TX_CURR TargetFY19 Target TX_CURRFY20 Target TX_CURRN

um

ber

of

PLH

IV

Increase in Current on Treatment by District Prioritization, FY17 to FY20

Attained ScaleUp Sat ScaleUp Agg Sustained

86

Aggressive Growth Planned in All Provinces

0

100000

200000

300000

400000

500000

600000

Cabo Delgado Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia

Nu

mb

er o

f P

LHIV

Projected Treatment Trend by Province FY17 to FY20 and Est. PLHIV (FY19)

FY17 TX_CURR FY18 TX_CURR Target FY19 Target TX_CURR FY20 Target TX_CURR Estimated # of PLHIV, end of FY19

0%

20%

40%

60%

80%

100%

120%

Cabo Delgado Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia Grand Total

Co

vera

ge

Projected ART Coverage Trend by Province, FY17 to FY20

FY17 Coverage FY18 Coverage FY19 Coverage FY20 Coverage

87

Targeting Growth Towards National 90-90-90 Targets in FY20

46%

58%

72%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

500000

1000000

1500000

2000000

2500000

FY17 FY18 Expected FY19 Target FY20 Target

Current on Treatment, Unmet Need, and Covearge, FY17 to FY20

Current on Treatment Unmet Need Coverage

88

Care and Treatment Budget Highlights

89

Key Approaches to Achieve Care and Treatment Objectives at the Site Level

90

Key Approaches to Achieve Care and Treatment Objectives at the Above-Site Level

91

Summary on Strategies to Reach Men in COP18

Core Strategies to Improve Identification, Uptake, and Adherence to Treatment among Men:

• Scale-up proven linkage strategies

• Ensure broad-scale dissemination of MISAU-approved DSD strategies

• Strengthen implementation of MISAU-guidelines on pyscho-social support

• Promote improved community-facility linkages

• Maximize efficiency of investments to maintain and scale-up core and cut-back on low-impact activities

92

Obrigada!

Questions?

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