1. ALL IN Assessments: what can we learn about quality of HIV health care services for adolescents? Dr. Chewe Luo, MD, PhD Associate Director, Programmes & Chief, HIV Section UNICEF New York

2. The Three Phases of the Country Assessments Decisions Key Steps National multi-sectoral participatory review & validation Strategic opportunities: Sectoral / cross-sectoral programme review, AIDS programme review, adolescent programme review etc and resource mobilization activities (e.g GFATM, PEPFAR) Key principle: adolescent and youth engagement at every step Survey, data abstraction & admin record Existing planning & monitoring systems (thematic / cross-sectoral) Phase 1: Rapid Assessment Phase 2: Targeted In-Depth Analysis Phase 3: Planning

3. Progress with implementation of the Country Assessments RegionPhase 1 (Review of data, confirmation of priority adolescent populations, locations, interventions) – 24 Countries Phase 2 (In-depth sub-national level analysis) – 6 Countries CEE/CISUkraine EAPRChina, Indonesia, Philippines, ThailandPhilippines (Cebu and Quezon Cities) ESARBotswana, Kenya, Malawi (DREAMS, SRH), Mozambique, Namibia, Swaziland, Tanzania, Uganda, Zimbabwe Botswana Namibia (CDC) LACJamaica MENA South Asia WCARBurkina Faso, Cameroon, Chad, CAR, Cote d’Ivoire, DRC, Gabon, Guinea Bissau, Nigeria Nigeria (Benue and Kaduna States)

4. 1.Takes forward priority interventions and populations identified during Phase 1 of the Assessment 2.Largely a system review of intervention pathway across coverage indicators on availability, accessibility, utilization and quality 3.Causal analysis of the observed coverage gaps Approach / Methodology

5. Scope of the analysis across the 3 countries Botswana*Philippines†Nigeria‡ Location & HIV Prevalence 4 Districts Barolong (20.3%) Boteli (20.3%) Gantsi (17.1%) Selebi / Phikwe (27.5%) 2 Cities Cebu city (16.7%) Quezon city (7.2%) MSM aged 20 year+ 2 States Benue (15%) Kaduna (7%) Focus is at Local Government Levels e.g. 10 LGA in Benue Target Population Adolescent GirlsYoung key populations Adolescent boys and girls Key Interventions (a) HTC, (b) ART, (c) Condom Use and (d) Voluntary Safe Male Circumcision (VSMC) (a) HIV Education, (b) HTC & (c) Condoms. (a) In-school HIV/AIDS prevention education (b) Condom Use (c) HTC, and (d) ART * Botswana AIDS Impact Survey (IV), 2013; † IHBSS, Philippines, 2015; ‡ HIV Sero-Prevalence Survey, Nigeria, 2014

6. Indicators for the analysis of gaps in HTC Barriers / BottlenecksIndicators CategoryDeterminants Supply Commodity Proportion of Health facilities providing HTC that report no stock- out of test kits in the last 3 months. Human Resource Proportion of health facilities providing HTC that have at least one health care workers trained to provide HIV testing and counselling for adolescents and young people. Accessibility Proportion of health facilities providing HTC that are adolescents / youth friendly (according to national standard) Demand Utilization Proportion of adolescents who report ever being tested for HIV in the last 12 months. Females 15-19 Male 15 - 19 Continuity Proportion of adolescents (aged 15‒19) who were tested and received results in the last 12 months. Females 15-19 Male 15 - 19 Quality Proportion of adolescents who tested positive for HIV and initiated on treatment in the last 12 months Females 15-19 Male 15 - 19

7. Indicators for the analysis of gaps in Condom Use Barriers / BottlenecksIndicator CategoryDeterminants Supply Commodity Proportion of health facilities that have no stock-out of condoms in the last 3 months Human Resource Proportion of health facilities with at least on trained staff for family planning counselling / services Accessibility Proportion of adolescents who know a source of condom Female Male Demand Utilization Proportion of sexually active adolescents who reported ever use of condom Female Male Continuity Proportion of sexually active adolescents who report current use of condom Female Male Quality Proportion of sexually active adolescents who report having multiple sexual partners and used condom in the last 12 months. Female Male

8. Indicators for the analysis of gaps in ART Barriers / BottlenecksIndicator CategoryDeterminants Supply CommodityProportion of ART sites with no stock-out of ARVs in the last 3 months. Human Resource Proportion of ART site with health care worker(s) trained to counsel adolescents and young people Accessibility Proportion of ART sites that have adolescent / youth friendly services (based on national standard) Demand Utilization Proportion of adolescents who tested positive for HIV and initiated on treatment in the last 12 months Aged 10 - 14 Aged 15 - 19 Aged 10 - 19 Aged 20 - 24 Continuity Proportion of adolescents who tested positive for HIV, initiated on treatment and are alive and still on treatment in the last 12 months Aged 10 - 14 Aged 15 - 19 Aged 10 - 19 Aged 20 - 24 Quality Proportion of ALHIV, who are on treatment and are virally surpressed (i.e. viral load of less than 1,000) in the last 12 months Aged 10 - 14 Aged 15 - 19 Aged 10 - 19 Aged 20 - 24

9. Data Gap Limited Capacity of HCW Limited number & not friendly Age of Consent Prevailing Stigma in Service Use Weak linkage of HTC & ART sites

10. Services not adolescent friendly Treatment buddy required to access service Limited coverage of CD4 monitoring Inadequate adherence counselling Data Gap include age disaggregation Data Gap

11. Limited number & not friendly Outreach sites in communities and not Health Facilities is the preferred location for HTC Limited linkage of outreach sites for HTC and ART sites

12. Limited negotiation power for females to use condom with sexual partners Data Gap from most LGAs Stock out of Condoms in Health Facilities Fewer girls know where to access condom

13. What did we learn? Unavailability of condoms hinders condom use (especially among high school students) Two components of condom use: knowledge & skill are important Knows that condoms protect against HIV QC: 83% Cebu: 77% Demonstrates correct condom use skills QC: 0% Cebu: 0% Condom use during last anal sex though increasing, remain low The Philippines

14. Examples of Proposed Corrective Actions 1.Addressing age of consent barrier & development of national protocol on adolescent / youth friendly service in Botswana 2.Set up coordination mechanisms across different sectors e.g. schools and health facilities for HTC and condom programme in the Philippines 3.Use of IT – solutions for demand creation, service optimization and tracking in Nigeria 4.Improve data system for age disaggregation

15. Next Steps: Nigeria The National Agency for the Control of AIDS (NACA) and partners are moving ahead with using IT solutions for demand creation and service optimization

16. Next Steps 1.Finalization of plans 2.Advocacy and resource mobilization 3.Implementation and tracking

17. Acknowledgement Ministries of Health, AIDS Commission and Partners from Botswana, Nigeria and Philippines UNICEF Country Offices in Botswana, Nigeria and Philippines UNICEF Regional Offices: ESARO, WCARO & EAPRO UNICEF New York (HIV Section and Data & Analytics Section) The Global ALL IN Working Group 2: UNAIDS, UNDP, UNFPA, UNESCO, UN Women, ILO, WHO, World Bank, AIDS Alliance, Ford Foundation, JSI, Save the Children, Global Fund, PEPFAR, PACT & UNICEF

18. THANK YOU