Sindy Matse Key Populations National Coordinator SNAP Swaziland Swaziland’s Experience of a Joint Global Fund/HIV Cascade Assessment to Improve the National Key Population Program Swaziland's Experience of a Joint Global Fund/PEPFAR HIV Cascade Assessment to Improve the National Key Population Program Sindy Matse Key Populations National Coordinator SNAP Swaziland Laura Muzart LINKAGES Country Representative FHI 360

Joint HIV Cascade Assessment Objectives Better understand and describe service flow at service delivery sites within the projects or within a certain geographical area (i.e., community-based, public sector, and hybrid models) Identify “leaks” in the system where KPs are lost to follow up or unable to access critical products or services in the WHO KP comprehensive package Identify successes for dissemination, scale-up and replication Recommend solutions and innovations for barriers, optimization of service delivery, and joint TA For the last bullet point: “Overview of South Africa PrEP and Test and Treat guidelines” – adapt according to audience, i.e. country, private or public sector, etc.

Swaziland Joint HIV Cascade Assessment November 16-21, 2016 Team Members Ministry of Health PEPFAR/USAID PEPFAR/CDC Global Fund WHO KP Implementing Partners Timeframe Period of alignment between Global Fund/PEPFAR KP program partners Period of transition between MOH/PEPFAR-funded programs At the start up of Global Fund’s KP program Approach Qualitative and Quantitative Tools: Facilities KP Representatives KP NGOs/CBOs KP Peer Cadre (Peer Navigators, Community Liaisons and Community Health Educators) Data Flow Charts Swaziland has a generalized HIV epidemic and new infections continue to occur despite major strides in the national response. HIV prevalence among Men having sex with Men (MSM) is 17.7% and high among sex workers at 70.3%. HIV prevalence is evenly distributed across the four regions in the country. HTS uptake among pregnant women has slightly decreased from 97% in 2014 to 90% in 2015. Positivity rate at ANC is 37% with 93% of these women on ART. Sero conversion amongst infants 6-8 weeks is still high at 3% despite significant reduction over the years. There is no national data on sero-discordancy in Swaziland. However, programme data indicate an average of 15.5% (MoH Routine data). Swaziland Global AIDS Report, 2014 Ministry of Health 2015 HIV Prevention Annual Report

The Leaky Pipe of the HIV Prevention, Care, and Treatment Cascade

Reach Key Findings: Informal mapping of KP hot spots Duplication of roles and responsibilities of community-based health care staff Poor coordination and collaboration between community-based health care staff Limited staff to support KPs and high client-to-provider ratios

Reach Recommendation Update Conduct rapid hot spot mapping and size estimation per venue Completed June 2017. Updated clinical mobile service schedule, condom and lubricant distribution, and outreach approach Microplanning around hot spots -Trained managers -Used data to prioritize hot spots for programming; community cadres training July 24-26, 2017 Develop clear scope of work (SOW) for community cadre -Combined cadres, aligned scopes and stipends -Standardized tools -Defined geographic coverage Establish safe spaces for FSWs and MSM Ongoing with outreach workers Implement innovative outreach strategies to increase reach to hard-to-reach areas and among KPs who have not tested. -Trained both groups of outreach workers on mobilization techniques -Conducting an Enhanced Outreach Services Campaign through July 2017 Update national package of services for KPs -Developed and rolled out Peer Education Manual, -Aligned clinical services provided to KPs

HIV Testing Services Key Findings KPs are heavily reliant on the mobile clinic which has no fixed schedule and infrequent visits Static clinics provide HTS, but are not considered KP friendly Recommendation Update Conduct targeted community-based testing -Lay Counsellors trained in HTS June 2017 -Roll out of HIV ST (1 region, scale up planned August 2017)

HIV Care and Treatment Key Findings KPs are heavily reliant on the mobile clinic, which does not provide ART and has no fixed schedule and infrequent visits Static clinics provide ART, but are not considered KP friendly Nascent Peer Navigation program (# of Peer Navigators, confidentiality, availability to provide services) Recommendation Update Conduct targeted community-based dispensing outside of fixed and mobile clinics -Provision of ART in mobile clinic (planned September 2017) -Begin CAG estimate in 1 catchment area (planned July 2017) Increase counselling skills of PNs to handle complex issues (e.g., stigma and discrimination, relationships, disclosure) -Trained all KP COWS on the Peer Education Manual including Peer Navigation -Trained supervisors on supportive supervision techniques

Viral Load Key Findings Backlog of viral load analysis KPs reported not knowing what a VL test was or why it was important Recommendation Update Viral load scale-up plan to ensure all eligible clients, including KP individuals, have access to viral load monitoring -National scale up of VL testing -Incorporation of Viral Load testing in the Peer Education Manual (in which KP COWs are trained) Ensure that viral load testing is incorporated into the operational plan for test-and-start Improve demand creation for viral load monitoring from KPs

Monitoring and Evaluation Key Findings Lack of denominators for hot spots Use of distinct data collection forms for different programs Recommendation Update Prioritize hot spot mapping and KP size estimation Completed mapping and size estimation Harmonize data collection forms -Aligned data collection forms for the community cadre -Conducted a joint training on tools -Developed a set of key M&E indicators with associated definitions and disaggregation guidance

Program Alignment and Coordination Alignment of M&E tools and reporting mechanism Geographical alignment for both programs to ensure coverage and minimize overlap Joint trainings on Peer Education, microplanning and Peer Navigation Joint hot spot mapping exercise by both CANGO (GF PR) and LINKAGES Outreach Workers Monthly coordination meetings between PEPFAR and Global Fund implementing partners and the MoH Joint review of program training materials & development of job aids

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