Service delivery: Targeting young people at risk – reach and 10 lessons learnt

2. Service delivery: Targeting young people at risk – reach and 10 lessons learnt Dr Saiqa Mullick, Wits RHI @WitsRHI Share your thoughts on this presentation with #IAS2019

3. South Africa NDoH PrEP Implementation Snapshot: 25 687 101 SITES CURRENTLY IMPLEMENTING ACROSS ALL 9 SA PROVINCES initiations Took place at 96 SITES across South Africa June 2016 – May 2019 Project PrEP, a Unitaid funded project, is working closely with South Africa’s National Department of Health (NDOH) to integrate oral Pre-Exposure Prophylaxis (PrEP) into comprehensive sexual and reproductive health (SRH) services for AGYW at 9 clinics across three provinces in SA.

4. Project PrEP objectives Increase accessibility of PrEP for eligible AGYW population (15-24) in project implementation areas Demonstrate effective delivery models and appropriate use of PrEP amongst adolescents Generate and disseminate evidence on the use of PrEP in real life settings • Develop strategies to identify AGYW at highest risk • Test various demand creation strategies • Test different HIV screening/testing mechanisms • Reach over 600 000 AGYW and initiate 6640 • Access AGYW through public facilities • Offer, initiate and retain AGYW on PrEP • Learn about how to deliver HIV prevention services, PrEP specifically, to AGYW • Gather evidence on cost-effective and successful service delivery mechanisms and interventions • Inform future scale up of PrEP Data sources Site-level monitoring reports M&E routine data AGYW survey data

5. Targeting those who need PrEP most AGYW aged 15-24 are targeted and efforts made to strengthen the implementation of expanded HIV combination prevention options, including PrEP in 8 selected clinics in 3 of the She Conquers priority sub-districts in 3 provinces. Clusters of facilities (include PHC clinics and roving teams providing outreach services) is assessed for capacity to provide PrEP and trained and mentored to deliver a comprehensive package of services and to implement the designated timeslots for youth friendly service delivery. • Selection is based on a mapping exercise identifying high priority clusters which meet a set of criteria: • Must be within a She conquers sub-districts • High HIV prevalence, number of schools, learners, teen pregnancy rates, STI, GBV • Clinics close to secondary schools / TVETS / Universities

6. Project PrEP Clusters • Cluster 3 Snapshot – Clinic 3A and 3B; Gauteng Province, Tshwane District: • Peri-urban • 902 633k Population • 214 673k AGYW Population (15-24 yrs) • Cluster 2 Snapshot – Clinic 2A and 2B; Eastern Cape Province, Oliver Tambo District: • Peri-rural • 66 605k Population • 15 430 AGYW Population (15-24 yrs) • Cluster 1 – Clinic 1A & 1B; Eastern Cape Province, Nelson Mandela Bay District: • Peri-urban • 74 985k Population • 17 372 AGYW Population (15-24 yrs) • Cluster 4 Snapshot – Clinic 4A and 4B; KwaZulu Natal Province, eThekwini District : • Urban/CBD • 2 188 896k Population • 507 138k AGYW Population (15-24 yrs)

7. Implementation model: Linking and attracting AGYW to PrEP • RESOURCES • Utilising existing NIMART trained nurse in clinic and other trained staff to provide PrEP to AGYW • Capacity building and mentorship of providers throughout the project • Assisting facility to create youth friendly zones and provide youth friendly SRH and HIV services • Roving unit equipped with NIMART nurse, counsellor and data capturer • Have provided one data collection clerk per clinic to support enhanced monitoring activities • Use biometric system to monitor AGYW, presenting in clinic and collect data on which services are accessed DEMAND CREATION OUTREACH ACTIVITIES – PARTNERS, YOUTH CONNECTORS & CBOs REFERRING AGYW TO ROVING UNIT OR CLINIC#1 / CLINIC#2 FOR SERVICES FIXED FACILITY CLINIC#1 – ANCHOR WITH TRAINED NDOH STAFF AND WITS RHI MONITORING STAFF ROVING UNIT ANCHORED TO THE FACILITY, REACHING SURROUNDING AREAS. REFERRING TO ANCHOR SITE FOR ONGOING CARE. CLINIC#2 – WITH TRAINED NDOH STAFF AND WITS RHI MONITORING STAFF • To monitor and feedback into the implementation of the intervention, innovative monitoring systems will be used. Tablet based data collection will be used in roving sites (with paper based back-up systems) and biometric fingerprint registration of all AGYW accessing services in all sites (fixed and roving). Allowing AGYW to access services at any of the sites and continue to be monitored.

8. Minimum clinical package

9. Project PrEP cascade Source: Routine Monitoring Data

10. Continuation is variable Clinic 1 Clinic 2

11. Lesson 1 A combination of strategies is needed to influence uptake June: Tertiary institutions and schools are closed, hence the low number of PrEP initiations. In April-May: Clinic activations • Feb-March: • Training on integration of PrEP and other SRH services • Strategic mapping of hotspots Source: Routine Monitoring Data

12. Lesson 2 Those AGYW coming for PrEP are at risk __ On average, AGYW’s partners are approx. 4 + years older. Twenty – forty percent reported partners 5-10 years older AGYW Survey data

13. Lesson 3 AGYW are motivated to use PrEP “Because I now know my status …so I want to protect myself from getting infected with HIV.” Data source: AGYW Survey data

14. Lesson 4 We need to build condom confidence Condom confidence is low! There is a need to go back to basics as many young women indicated being unsure of how to use male condoms. But… AGYW feel confident that they can use PrEP! Data source: AGYW Survey data

15. Lesson 5 Know your population:a menu of strategies needed at each level Strategies used to identify PrEP clients at the hotspots Strategies used to identify PrEP clients at the mobile clinics Strategies used to identify PrEP clients at fixed facilities Strategically mapped hotspots to access AGYW. Reached AGYW at winter schools where available. Ensuring continuity at fixed facility - PrEP nurse always available for initiation encourages AGYW to access facility services. Mobile clinic convenient for AGYW - opportunity to build good rapport, trust and confidence with mobile clinic teams - same professional nurse and her/his team servicing AGYW while facilities staff are inconsistent Hotspot visits at academic institutions such as TVETS, Universities, Colleges, high schools reaches target group and appropriate age. Ensuring presence of youth friendly nurse champions at facilities to promote youth friendliness - increase in number of AGYW visits. Extend working hours and Conduct hotspot visits on weekends.

16. Lesson 6 We need a menu of strategies to combat discontinuation Strategies to address the gaps Reason for Discontinuation of PrEP Strategies used to retain PrEP clients • Peer support through social media such as WhatsApp groups, e.g. a facility in KZN set up PrEP WhatsApp group for all AGYW who are taking PrEP • Behavioural counselling and regular follow up through the telephone, e.g. in Gauteng, the lay counsellor does this regularly. Provide PrEP supply to last during holiday periods. + Refer to www.myprep.co.za/locationsto access PrEP from their nearest PrEP providing health centre Long school holidays with no access to a facility Lack of support from parents /guardians to AGYW Continue with parent/caregiver/ community dialogues on oral PrEP to encourage support for AGYW taking up PrEP and continuing • Frequent contact with client on PrEP especially trained counsellors to provide detailed counselling to PrEP clients. Facilitate decision making by client e.g. service provider would ask client (AGYW) “when would you like to come back” and help them to cope with the need for frequent follow up. AGYW are not comfortable with community members seeing them at fixed facilities Offer them an option to visit the mobile clinic

17. Lesson 7 AGYW need more than PrEP AGYW Survey data Scale reference: Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613. doi:10.1046/j.1525-1497.2001.016009606.x

18. Lesson 8 Integration is beginning to happen Source: Routine Monitoring Data

19. Lesson 9 Multiple strategies for integration required Integrate oral PrEP into other SRH services e.g STI management and Family Planning Ensure that nurses are trained on NIMART, oral PrEP and how to integrate services Provide a mobile clinic van which is a one-stop shop service points of oral PrEP and SRH Establish youth clinic that provides comprehensive health care services including SRH & PrEP Ensure constant communication with facility teams through quarterly meeting to reinforce on the importance and advantages of integration of services Establish strong referral network within and beyond facility in circumstances where you do not have adequate trained personnel

20. Lesson 10 Get out of the clinic! • Over 50% of PrEP clients are AGYW and other young people who come to the mobile clinic because the team maintains privacy. • It is easy to build rapport, trust and confidence with mobile clinic teams - usually the same professional nurse and her/his team - while at facilities staff change a lot. • Young people prefer a one-stop shop and integrated services in their community (mobile clinic van brings services closer to the client). • There is flexibility to extend working hours to include weekends – this allows AGYW to access services when fixed facilities are not operational. • It increases the number of AGYW reached with PrEP initiations. This mobile clinic is convenient, non-stigmatising and meets us where we are…

21. Lesson 10 Mobile van reach is significant Source: Routine Monitoring Data

22. Acknowledgements • And Wits RHI staff: • Vusile Butler • Nicolette Naidoo • Elmari Briedenhann • Maserame Mojapele • ZukiswaFipaza • Bongai Mundeta • Stanley Molefe • Letitia Rambally-Greener All photographs used are courtesy of Adobe Stock, standard licensing – appearance in a photograph in this presentation does not indicate a person’s health status. Shona Dalal (WHO) Rachel Baggaley (WHO) Heather Ingold (Unitaid) Unitaid for funding the Project PrEP initiative. Project PrEP facility staff and mobile teams. Hasina Subedar and DOH Staff

23. Thank you!