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 24th July 2018

Presentation Outline Background Description Lessons Learned Conclusion 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

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 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

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

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)

FHI 360 Community Index Testing Process Community HTS initiatives

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

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

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

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

Age/Sex disaggregation of People Reached Oct 2016 to Sep 2017 Males tested for HIV: 11,754 (48%) Adult men (>15 yrs): 10,883 (93%) Adult men identified as HIV+: 3,705 (34%) In Conclusions This CIT coupled with SNT is an efficient approach. It increased the total number of HIV positive persons identified while decreasing overall testing volume One HIV positive person was identified for every 1.77 index case followed up FHI360 achieves and sustains a high yield among individuals tested for HIV using the community HIV index-testing model. This model is reaching people living with HIV who would not ordinarily access HIV testing services (HTS) from the conventional health facility HTS modalities. By going into the community, FHI360 is identifying a critical group of people who are living with HIV and facilitating their treatment initiation. FHI360 is leveraging its community platform to reach a high proportion of men of reproductive age with HIV services.

Sexual network testing introduced Efficiency of Community Index HIV Testing with Sexual Network Testing: Apr 2016—Sep 2017 Sexual network testing introduced One HIV positive person identified for every 1.8 index cases

High Yield Achieved on the FHI 360 ZHCT Project: Apr 2016—Sep 2017 Sexual network testing introduced Ave yield 38% with SNT Yield in sexual partners 44%

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

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

Acknowledgements PEPFAR/USAID Ministry of Health and Child Care ZHCT Project Beneficiaries ZHCT Project Staff AIDS2018 .

Auxilia Muchedzi- ZHCT Project Deputy Chief of Party Contact details: Auxilia Muchedzi- ZHCT Project Deputy Chief of Party Email: amuchedzi@fhi360.org www.fhi360.org

BACK POCKET SLIDES

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

FHI360 Community Index HIV Testing Program Quality Assurance Community Program implementation is guided by SOPs Job Aides FHI360 pioneered the development of Community M&E system and tools Community HIV testing quality assurance system

FHI360/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%,   Children: Tested 1,794,  HIV+308, Yield 17% Sexual Partners: Tested 14,301, HIV+ 6,255 , Yield 44% Others: Tested 8,506 , HIV+ 1,921, Yield 23%

Cohort analysis showing time to ART initiation: Makoni vs Mutasa District, Oct 2017 – May 2018 Makoni has more than 50% same day initiation but in 30days they linked 90% by 30th day No community ART initiation in Mutasa Community ART initiation: initiating ART at community level through collaborating with MOHCC facility based or OPHID DSD nurses