Reaching the first “90”: Decentralizing and strengthening Provider Initiated Testing services at primary health care facilities in Ukraine Mariya Makovetska, USAID HIV Reform in Action Project, Deloitte consulting LLP

BACKGROUND: UKRAINE Ukraine: Country in the middle of Europe With high level of HIV-burden And centralize approach to healthcare provision

BACKGROUND: UKRAINE To achieve the first “90” of the UNAIDS targets, it is necessary to diagnose 83,222 PLWH. *indicates UNAIDS 90-90-90 benchmarks. Currently targets for the number of persons aware of their status are off by 34% (83,222 patients), ART medication targets are off by 41%, and viral suspension targets are off by 50%).

BOTTLENECKS OF THE EXISTING HIV DETECTION SYSTEM IN UKRAINE Limited # of “entry points” into the cascade of HIV prevention and care – HCF only. HCT services concentration at specialized facilities. Lack of the HCT services at rural areas. Health facilities still do not provide adequate HTC services and have high level of stigma, discrimination and refuses in medical care – 8%*. Hight patients drop-out rate between HIV diagnostic and registration – 738.8 thousand people (23.7%) in 2014**. HIV testing is provided on an opt-in basis. HIV testing, pre- and post-test counseling and the preparation and delivery of test results can be provided by health facilities (regardless of their ownership and subordination), social support services and other organizations working to prevent HIV. These facilities must be fully licensed to carry out such activities and have an accredited medical laboratory. Ukraine’s current legislation has no regulations addressing self or home-testing for HIV. 738.8 thousand people (23.7%) last year lost opportunity to do the full HCT cycle, know about their HIV status and, if test for HIV is positive, receive HIV services, including antiretroviral therapy. *PLWH Stigma Index Survey. Ukraine, 2016. ** HIV Patient Pathway. USAID HIV Reform in Action Project. 2015

USAID “HIV REFORM IN ACTION” IMPLEMENTATION OBLASTS Poltava: Kremenchuk City Poltava City Kyiv City Dnipropetrovsk Kryvy Rih City Kryvy Rih Rayon Cherkasy Kaniv City Odesa Bilhorod-Dnistrovsky City Bilhorod-Dnistrovsky Rayon Odesa City PLHIV estimates are in-house PEPFAR estimates used in COP18 planning, prior to availability of official subnational PLHIV estimates Estimate for Donetsk was for government controlled areas only Est. PLHIV in PEPFAR focus oblasts Kherson Kherson City Mykolayiv Pervomaisk City Pervomaisk Rayon

PROBLEM SOLUTION: Decentralizing HTC services to expanded network of primary health care providers: Geographic: 14 cities/rayons across 7 regions Timing: March 2016 and December 2017. Key tasks: Advocacy for local funds allocation; Training for PHC personnel in HIV testing services; Removing local policy barriers; Introduction rapid testing for HIV diagnosis. Decentralizing HTC services from regional level AIDS centers and local hospitals to the expanded network of primary health care centers (PHC): Key tasks: Advocacy for local funds allocation for rapid HIV tests from local budgets; Training for PHC personnel in HIV testing services; Removing local policy barriers for the provision and scale-up of HCT services; introduction of policies to use 2 rapid tests for HIV diagnosis.

HIV COUNSELING AND TESTING SCALE-UP USING 2 RAPID TESTS IN PRIMARY HC FACILITIES, 2015-2017 25 PHC providers in 2015 to 225 in 2017

HIV RAPID TESTING SCALE-UP IN 14 PILOT ADMINISTRATIVE AREAS: 2015, 2016, AND 2017 All sites allocated funds for procurement of rapid test kits resulting in 6 time increase in rapid test supply compared to the previous year.

TRAINING FOR PHC PERSONNEL IN HIV TESTING SERVICES Total number of people trained – 1241, and out of this number 565 – Physicians, and 676 - Mid level medical Personnel: nurses, laborants, psychologists

CONCLUSIONS: Increasing the number of HTC service delivery and patient entry points to the health care system will expand testing services beyond traditional entry points and help detect HIV patients coming to HCF for regular primary health care services. To sustain the outcomes, local authorities need to invest in training of human resources, infrastructure, and other health-system-strengthening components, as well as increase local budget allocations for HIV services.

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