Increasing Coverage of HIV/AIDS Services through Government-Led District Mentorship Teams: A Case of Livingstone District in Southern Province, Zambia Charity Bwalya,1 Christopher Bwale,1 Lola Aladesanmi,1 Hillary Musole,2 and Mando Mwaba2 1Jhpiego Zambia, 2Livingstone District Health Office, Ministry of Health Zambia

HIV/AIDS in Zambia Population Size Estimate (2016) 16.7 million HIV Prevalence (15-59 years) Overall: 12.3% Females: 14.9% Males: 9.5% (1.2 million PLHIV) Northern, 9.7% Luapula, 9.3% Muchinga, 5.9% Copperbelt, 14.2% North Western, 6.9% Central, 13.4% Eastern, 8.2% Overall Range Lusaka, 16.1% Western, 16.0% 16.1% Southern, 13.4% 5.9%

HIV/AIDS in Zambia Since 2011 Zambia national HIV/AIDS strategic framework has prioritized accelerating universal access for PLHIV, their caregivers and families to comprehensive treatment, care, and support

Challenges to achieve 2011 priority Geographical access rural communities experience difficulties in accessing health facilities that provide ART Shortage of skilled health care providers

Project Background Jhpiego is implementing a 5-year (2015–2020) project funded by the Centers for Disease Control and Prevention through the U.S. President’s Emergency Plan for AIDS Relief. Project’s geographical foci are Southern, Lusaka, Western, Copperbelt, and Central Provinces in Zambia. Objective Build and maintain a competent workforce to deliver quality services (ART, elimination of mother-to-child transmission [eMTCT] of HIV, and TB) Method Establish an operational, district-based, in- service training system that follows a blended- learning approach that includes: onsite clinical mentorship e-learning North Western Western Northern Luapula Muchinga Eastern Central Southern Lusaka Project Presence Livingstone District Copperbelt

Onsite Clinical Mentorship Approach Step 1: Preparation Step 2: Start-up Step 2: Rollout

Step 1: Preparatory Phase (2015) Consultative/introductory meetings at provincial and district levels Needs assessment Availability of provincial/district mentorship teams Team composition Materials used Monitoring system Orientation on the Jhpiego-pioneered mentorship approach Planning Meetings

Step 2: Start-Up Phase (February 2016) Establish District Mentorship Training Team (DMTT) [20 health care workers selected from the following) District Health Office (part of lead HIV program staff) Secondary health facilities Train DMTT on generic mentorship skills and teaching skills Provide technical updates on current ART, eMTCT, and TB guidelines Conduct objective structured clinical exams to reinforce their skills, so they could mentor others

Step 3: Rollout Phase led by DMTT (May 2016 – Current) Site mapping/identification Needs assessment (personnel, skills, space, commodities) Introduction of the district mentorship initiative to scale up ART services Supplying facilities with ART commodities Identifying ART focal person Identify mentees (ART service delivery providers) Designate ART service delivery space within the facility Provide onsite mentorship and coaching on designated clinic days by working with the providers hand in hand M&E forms, Specimen bottles, ART ordering

Mentorship on creatinine clearance calculation Mentors facilitating order and delivery of antiretroviral medication Photos by: Jocelyn Hibeene

ART Provision Skills Taught During Mentorship Medical History Taking & Conducting head-to-toe physical examination Managing side effects, toxicities, and adverse effects from ART Initiating adult and children on ART (cART) Counseling patients on treatment and appointment adherence Monitoring adult/ children

Rollout Phase led by DMTT (May 2016 – Current) Mentors continue to support provision of ART services in the sites until the providers become competent to run the clinic themselves (i.e., they no longer require mentoring). There have now been 10 rounds of mentorship visits in the Livingstone District. Mentorship on prebaseline ART investigations

What was accomplished? 20 DTT identified and trained DTT mentored 18 health care providers who were working at facilities that did not provide ART services. Mentorship contributed to the expansion of ART services from six sites in May 2016 to 22 sites in January 2017. 2,083 clients have been started on ART at the 16 new sites (ART coverage in the district has increased from 34% to 67% (estimated)1–3 2016. Zambia population-based HIV impact assessment (ZAMPHIA) 2015–2016 fact sheet. PHIA Project website. http://phia.icap.columbia.edu/wp-content/uploads/2016/09/ZAMBIA-Factsheet.FIN_.pdf. [Published December 2016.] Accessed November 29, 2017. Central Statistical Office Zambia, Ministry of Health Zambia, ICF International. 2014. Zambia demographic and health survey 2013–2014. Demographic Health Surveys Program website. https://www.dhsprogram.com/pubs/pdf/FR304/FR304.pdf. Accessed November 29, 2017. Zambian Health Management Information System [Database] (accessed November 29, 2017), https://www.zambiahmis.org/dhis-web-commons/security/login.action.

Expansion in the coverage of ART services in Livingstone District (May 2016 to May 2017) Map showing coverage in May 2016 Map showing coverage in May 2017 A new TB treatment center opened at an army clinic in Livingstone (staffed by two TB mentees of DTT)

Lessons Learned Mentorship increased skills and confidence to effectively deliver services Government-led mentorship teams enable mentors and mentees to be accountable to and own the mentoring process (ownership). For the mentee, mentorship creates a supportive environment and an ongoing relationship with a key government counterpart/mentor who resides in the mentee’s district (supportive environment). Mentorship has broken organizational barriers across different levels of health facilities, resulting in improved referral networks (coordinated referrals).

Lessons Learned (cont.) Mentorship has resulted in consistent commodity supplies (reduced stock-outs). District antiretroviral stock-out rates decreased from 12% in the first quarter of 2016 to 5% in the fourth quarter of 2016. Mentorship activities improved communications among the province, district, and health facilities.

Next Steps Government-led DTTs have been instrumental in increasing coverage of HIV/AIDS services by enabling the Ministry of Health to own the clinical mentorship process. The project has now scaled up these services to four additional districts and is sharing tools and processes with other Centers for Disease Control and Prevention partners to replicate across their supported districts. The project is improving its data collection systems to systematically measure improvements in provider competencies and quality of services delivered.

Acknowledgments The Project thanks the Provincial Health Director of Health, Southern province, Livingstone District Health Director , the Jhpiego Zambia Country Director, and the abstract review team. This work has been supported by the Centers for Disease Control and Prevention through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The opinions expressed in this presentation are those of the authors and do not necessarily reflect the views of PEPFAR or the United States government.