Opening Ceremony of Afar HAPCO DIC For FSWs

at Logia Town.

June 22, 2023

Afar HAPCO DIC, Logia
 Outline
• Background

– Epidemiology of HIV (Global and National)

– 95-95-95 performance

• Performance Report

– Federal level performance

– Regional Level key performance

• Key challenges and actions taken

• Way forward
2
Goal and Objectives of Road Map 2.0

 The goal is to attain epidemic control by 2025

 Both new infection and AIDS death <1/10,000 population
 Reduce the number of new infections to < 7400
 Objectives by 2025
 Reach 95% of KPP with combination prevention – Behavioral, biomedical and structural
interventions
 90% of KPP use condoms at last high-risk sex
 90% of Eligible people access PrEP
 VMMC coverage reaches 90% in high-incidence regions (Gambella)
 Reach 90% of PWID with needle syringe and 40% with OST
 Reduce stigma and discrimination among PLHIV below 10%
 Ensure there are policies and legal frameworks that support HIV programs targeting KPPs

3
 Population and Geographic priorities
National Incidence Category contextualized to local
Population Priorities context

 Three key populations District-level HIV District-level HIV

 FSWs incidence incidence category
 PWID < 0.01 Low
 Inmates
0.01-0.029 Moderate
≥0.03 High (265)
 Five priority populations
Global AIDS strategy Incidence Category
 High-risk AGYW
 Distance drivers
 Widowed and divorced District-level HIV District-level HIV
incidence incidence category
 Workers in hot spot places/migrant workers
 Discordant couples < 0.3 Low
0.3-0.9 Moderate
Geographic Prioritization
1.0-2.9 High
 Prevention focuses on 265 high-incidence woredas
>3.0 Very High
4
 Scale up Combination HIV prevention
Package of services
 Condom program
 ARV-based HIV prevention
 Harm Reduction and OST
 VMMC
 STIS screening, diagnosis, and treatment
 Demand creation
 Integration of HIV education in curricular and
extracurricular activities of schools
 Prevention and management of GBV
 Economic Empowerment of AGYW
Service delivery models
KPP-friendly Clinics and DICs
Make general HIV services KP friendly
Integrated HIV prevention services
SRHR/FP, VMMC, harm reduction, TB,
Mental health, hepatitis, etc
Prison, workplace, school
Targeted outreach
Community-based services – peers and
community workers
Social marketing & private sector
Mapping and size estimation of KPPs
District level every 2 year
5
Background: Epidemiology of HIV-Global(2021)
Estimated number of PLHIV Annual HIV new infection Annual AIDS related death
 Background …National HIV situation in 2022
Estimated number of Annual HIV new Annual AIDS
PLHIV infection related death

610,000 8,300 11,000

(510,000-750,000) (4,000-18,000) (6900-20,000)
570,000(93.9%) 6,000(70%) 9,800(86.4%)

350,000(61%) 4,100(68%) 5,100 (52%)

220,000(39%) 1,900(32%) 4,700(48%)

37,000 (6.1%) 2,000 (30%) 1,500(13.6%)

Source: 2022 spectrum Estimates and Projections in Ethiopia

 Background …National HIV situation among adolescents and young
people -2022
Estimated # Annual HIV Remark
of AYLHIV new
infection

Adolescent Girls, aged 10–19 21,000 (51.22%) 82088.2% annual new infection among
years Vs Adolescent adolescents are Adolescent -girls Vs
men (48.78%) Adolescent men (11.8%)-110

Adolescents, aged 10–19 41,000 930

Young Women, aged 15–24 36,000(59%) Vs 1,900 79.2% annual new infection among young
Young Men 41% people are Young-women Vs Y-M (20.8%)-500

Young people, aged 15–24 61,000 2,400 30.2% annual new infection among
Youngofpeople
 Young Women, aged 15–24 years contribute 10.1% of the total population age
Ethiopia but15+
23 % of total annual
new HIV infection
 Young people, aged 15–24 years contribute 20.5% of the total population of Ethiopia but 29% of total annual new
HIV infection 8
Intro…..
National
 In 2022 estimate nationally 36,812 CLHIV

14,725 (40%)- known status,

13,057 (88%) -on ART (DHIS-2) 40 % 88 % 92%

501,272.212 ---87.4
 Across the three 95 for children 40/87/92 ( adult
515,997.012..total 1st 95.. 84.5 87/90/97)
 There is significant Inequality
 Far behind in the progress towards meeting the
first 95 in 2025
 HIV Positives by region , Tir-Megabit

SWE
Somali
SNNP 2% 4% AA
7% 16%
Sidama
2%
Afar
2%
Oromia
14%

Harari
Gambella
0%
3%
DD
3%

Amhara
48%
 Care and Treatment Source –DHIS-2

Indicator Performance
Tir Yekatit Megabit Total
2.1 Number of children  12,488 12,887 13057
currently on ART
2.2 Number/Percent of 84 130 115 329
children started on
ART(Tx_NEW)
% of HIVRST utilization 3 month( Tir-Megabit 2015 EFY-
KOBO data)

HIVRST Utilization
Tir Yekatit Total
Megabit
AA 93.3% 94.6% 95.7% 94.7%
Afar 40.4% 21.9% 25.0% 29.0%
Amhara 36.3% 43.0% 44.9% 42.1%
Ben-Gum 80.1% 65.9% 87.6% 78.0%
DD 87.0% 86.1% 42.6% 79.2%
Gambella 54.8% 52.3% 70.5% 60.0%
Harari 97.0% 79.9% 66.7% 77.9%
Oromia 84.2% 90.5% 90.3% 88.4%
Sidama 36.0% 40.4% 52.2% 42.1%
SNNP 58.3% 54.3% 78.8% 62.2%
HIV CS Data Use : Epidemic and programme monitoring
HIV CS Data Use : Epidemic and programme monitoring
HIV CS Data Use : Epidemic and programme monitoring
 Status of HIV Prevention

Current HIV Status Combination HIV Prevention Status

 Ethiopia is close to attaining Epidemic Control
 National HIV incidence for 2021 is 0.01%  Condom at last sex with a non-regular partner is less
 AGWY account for 30% of new infections than 50%
 HIV Prevalence 0.9%  Only 70% of FSWs reached with combination HIV
prevention
 Urban 7X the rural (2.9% vs 0.4%)
 The number of new HIV infections had reduced from
 Regional variation - Gambella, AA, Harari, and 16,442 in 2016 to 11,702 in 2020 (EPHI 2022)
Diredawa 2.5 -3.6%
 KPs most affected - HIV prevalence 18.3% among
FSWS in 2020


17
17
Background 95-95-95 performance
Performance status of the three 95%, 2022
120%

100% 0.98 0.98 0.98

0.91 0.92
0.87 0.84
0.83
80%
Children age 0-14 years
Adults age 15+ years
60%
All age
0.4
40%

20%

0%
% of PLHIV who know their status % of PLHIV who know their status % of people living with HIV on ART
and who are on ART with suppressed viral load

NB: ART coverage from total PLHIV =83% and VL suppression from total PLHIV is 75%
2.5. STI cases seen and tested for HIV(DHIS2)
Region Number of STI cases seen Number of STI cases tested for
HIV
9 month Number Percent (%) Tested Positive Yield
target
Afar 6,250 719 11.5% 745 109 14.6.%

19
2.9. PMTCT

20
2.9. PMTCT…
% of Pregnant women tested for syphilis -2015 EFY-9 month performance (Source DHIS2)
100.0 97.2149963796294
91.0627523438035
89.2900788801244
90.0

78.8773757309941
80.0
72.671458845241 74.9635479304803
70.3625110521662
70.0

60.0 57.2815533980583 56.1828745818417

51.1718037570673
50.0
43.3881169259323 45.9381152749518
40.0 37.0252876699868
30.0

20.0

10.0

0.0
National Addis Afar Amhara Benishangul Dire Dawa Gambella Harari Oromiya SNNP Sidama Somali Southwest
Ababa Gumuz Ethiopia
21
2.9. PMTCT…
% of Pregnant women tested for HBV -2015 EFY-9 month performance (Source DHIS 2)
100.0 96.5961811794363
91.3296379935674
90.0
82.3241862015332
80.0

70.0 66.3120793821419
60.2016872576306 62.1489400584795
60.0 58.6459517494
52.3594490855724
50.0 46.6031369688127
42.0398648782126
40.0 37.4050648367481
31.0178120781736
30.0 26.0301541820166
20.0

10.0

0.0
National Addis Afar Amhara Benishangul Dire Dawa Gambella Harari Oromiya SNNP Sidama Somali Southwest
Ababa Gumuz Ethiopia
22
2.9. PMTCT…
% who received ART to reduce the risk of MTCT-2015 EFY-9 month performance(Source DHIS 2)
108.140639847957
100.0

90.0 86.0385144429161
82.4884792626728
78.917752977586
80.0 76.5700483091787
71.5953307392996
69.2307692307692
70.0
62.406015037594
60.0
53.0882352941176
50.4109589041096
50.0 45.8762886597938
43.0555555555556
40.0

30.0 27.9239766081871

20.0

10.0

0.0
National Addis Afar Amhara BG Dire Gambella Harari Oromiya SNNP Sidama Somali SWE
Ababa Dawa
23
2.9. PMTCT…
HIV exposed infants who received an HIV test within 12 months of birth( Source DHIS2)
100.0633512828
63 109.79
100.0

90.0
76.95852534562
74.27785419532
21 73.67149758454
80.0
71.72 32 11 66.32352941176
70.0 47
58.75486381322
60.0
96
44.36090225563
43.07692307692
50.0
91 31 36.71232876712
40.0
28.94736842105 33
26
30.0
18.98148148148
20.0
15

10.0

0.0
National Addis Afar Amhara BG Dire Gambella Harari Oromiya SNNP Sidama Somali SWE
Ababa Dawa
24
2.9. PMTCT…
HIV exposed infants who received an HIV test within 2 months of birth (source DHIS 2)
100.0

90.0

80.0

70.0 68.2293316439658
61.7511520737327
59.7661623108666 60.82
55.5472193566539
60.0

50.0
43.0769230769231
40.0966183574879 41.0294117647059
39.0977443609023 39.7859922178988
40.0

30.0 24.9315068493151
19.5906432748538
20.0
12.962962962963
10.0

0.0

25
2.9. PMTCT…
100.0
Percentage of HIV exposed infants who received ARV prophylaxis (Source DHIS 2)

90.0
76.655052264808
80.0 4
Low performance
70.0 68.421052631579 in most of the
58.459422283356
53.390227890837
3 regions
60.0
5 46.303501945525
45.410628019323
50.0 40.092165898617 7 3
38.461538461538
5 36.764705882352
40.0 5 9
28.240740740740
7 24.122807017543
30.0
9 26.027397260274
17.010309278350
20.0 5
10.0

0.0
National Addis Afar Amhara BG Dire Gambella Harari Oromiya SNNP Sidama Somali SWE
Ababa Dawa
26
 SO2: Enhance HIV case finding to attain 95% of PLHIV knowing their HIV
status and linked to care
&
SO4- Enroll 95% of PLHIV who know their status into HIV care and treatment
and attain viral suppression to at least 95% for those on antiretroviral treatment

27
 • Untargeted
testing
• 71% of HFs
visited did not
routinely use RAT
• Greatest yield is
from ICT

HIV Testing Number of Tests Number with Yield in %

Strategy Conducted Positive Test
Results
ICT/PNS 33,144 3,348 10.1
VCT 563,158 6,799 1.2
PITC 3,563,269 17,946 0.5
28
3.1 HIV testing and counseling service

2015 EFY 9 months HTS performance and yield by region

160% 1.41682944578 3.5%

498
0.03063762435936
140%
09 3.0%
1.10658254890 1.08116900531
120%
18 1.04103796002
0.91940916408
0.91773471127 587 217 0.92101659570
2.5%

100% 0.83405367888
379 7494 0.79085118257 7707
3566 2215 0.72176885991 2.0%
Testing perf

80% 2251

yield%
0.01425296371150 0.53670537389 1.5%
60% 19 2807
0.36714572386
3544 1.0%
40%
0.18253655021
0.00721182739693
0.00670497365300
0.00660556625602 0.00602645587423
0.00537090863136
097 0.00565888119953 0.00532390941618
20%
709 025
611
6726 864 0.00412256154438
0.00334244924642 668 0.5% 129
151 0.00240554977341
902 0.00134506132417
665
0% 748 0.0%
Addis Ababa Afar Amhara Beneshangul Dire Dawa Gambella Harari Oromiya SNNP Sidama Somali SW Ethiopia National

Tested Yield (%)

29
Tested 4.78 million HIV pos 26,385
3.1 HIV testing and ….
HIV testing and counseling service (Testing and yield% by Modality )
Region PITC VCT ICT
Tested _ Positive Yield(%)** Tested Positive Yield(%) tested positive Yield(%)

Addis Ababa 328,687 4,229 1.3% 69,125 1441 2.1% 13389 1156 9%

Afar 62,549 412 0.7% 14,810 99 0.7% 803 43 5%

Amhara 838,205 5,264 0.6% 227,571 1882 0.8% 15095 929 6%
Beneshangul 21,930 98 0.4% 9,722 72 0.7% 136 35 26%
Dire Dawa 45,379 301 0.7% 4,539 59 1.3% 234 26 11%
Gambella 19,394 529 2.7% 7,142 284 4.0% 561 85 15%
Harari 25,630 120 0.5% 2,114 37 1.8% 68 3 4%
Oromiya 1,904,727 5,822 0.3% 223,054 1290 0.6% 11667 1426 12%
SNNP 439,695 1,703 0.4% 53,445 330 0.6% 2500 359 14%
Sidama 223,106 493 0.2% 23,823 101 0.4% 591 110 19%
Somali* 98,931 523 0.5% 14,075 517 3.7% 106 8 8%
*Somali=DQ,Ferfer
SW Ethiopia HC ,Kebribeyah
97,556 Hospital,
571 Hamle 0.6%
2014 and Megabit&Tir
14,782 2015,9M
106 -National-corrected
0.7% 422with data from
83 DATIM
20%
**1.1% PITC yield
National when excluding
4,105,813 19,730 PMTCT
0.5% testing
664,226 5,880 0.9% 45,596 4,297 30 9.4%
3.1 HIV testing and ….

2015 EFY 9 months HTS by population group (Tested positive and Yield%)
17000 9.0%
16000 15388
15000
0.079557195571955 8.0%
Positive 14000
7
13000 7.0%
Yield(%)
12000
11000 6.0%

10000
5.0%
9000
8000
4.0%
Tested Positive

7000
0.032792424052282
6000

Yield (%)
5 0.026859353331873 3.0%
5000
4000 3397 6
0.014250520829207
2965 2.0%
3000 0.012239514639936
1799 0.013120567375886 0.010934301993251
2000 6 5 1617
7 0.006576810652809 3
1.0%
232 368 81 0.004153397145794
1000 74 35
0 0.0% 55

31
 HIV Testing
Challenges
• Limited targeted testing and low yield
• PICT – low yield
 Inconsistent use and low sensitivity
of Risk assessment tool
 High workload, lack of commitment
• Limited coverage of ICT (high-yield tests)
 Legal protection of health workers
eliciting contacts
 Low disclosure to partners, refusal,
and wrong address
• Repeat testing for SNS strategy
• Slow uptake of HIVST - lack of
community awareness and limited back
reporting
• Limited access for VCT of the general
population
• Frequent stockouts of RTKs
Recommendations
• Validate the risk screening tool to improve its
sensitivity
• Optimize utilization of the HIV risk screening
tool and documentation  
• Increase ICT
 Legal protection of health workers,
 partner disclosure counseling & reducing
stigma
 Enhancing peer navigator, case manager,
and adherence support activities.
• Improve uptake and reporting of HIVST
targeting high-risk groups, social marketing,
pharmacies
• Fee-based testing access for VCT of the
general population
• Strengthen PSM –RTKs
32
3.2 Linkage to care and ART initiation(Source DHIS 2

Region Total Positive Newly Started ART Percent Linked to

identified ART(Proxy Linkage )
Addis Ababa 5,670 5618 99%
Afar 511 411 80%
Amhara 7,146 5866 82%
Beneshangul 170 173 102%
Dire Dawa 360 306 85%
Gambella 813 957 118%
Harari 157 142 90%
Oromiya 7,112 6731 95%
SNNP 2,033 1803 89%
Sidama 594 547 92%
Somali 152 138 91%
*Somali=DQ,Ferfer HC ,Kebribeyah Hospital, Hamle 2014 and Megabit&Tir 2015 , Total POS of 1040 corrected from DATIM , 9M -National-corrected 33
3.3 PLHIVs Who are Currently on ART, Megabit 2015; DHIS2
Region Plan Achievement
Adults (age 15+) Children (0-14) Total %
Adults (age Children Total Number % Number %
15+) (0-14)
Addis Ababa 106,372 2,171 108,543 106,719 100.3% 1,467 68% 108,186 99.7%
Afar 5,377 382 5,759 4,715 87.7% 97 25% 4,812 83.6%
Amhara 161,999 5,750 167,749 148,549 91.7% 3,468 60% 152,017 90.6%
BGumuz 5,176 155 5,331 4,173 80.6% 108 70% 4,281 80.3%
Dire Dawa 9,551 216 9,767 6,840 71.6% 110 51% 6,950 71.2%
Gambella 11,169 539 11,708 8,339 74.7% 393 73% 8,732 74.6%
Harari 4,520 100 4,620 4,093 90.6% 62 62% 4,155 89.9%
Oromiya 125,128 6,028 131,156 118,618 94.8% 4,332 72% 122,950 93.7%
SNNP 27,569 1,278 28,847 27,519 99.8% 945 74% 28,464 98.7%
Sidama 12,684 696 13,380 10,252 80.8% 282 41% 10,534 78.7%
Somali 1,970 235 2,205 2,064 104.8% 64 27% 2,128 96.5%
Southwest 8,269 288 8,557 7,614 92.1% 302 105% 7,916 92.5%
Tigray 41,316 1,614 42,930            
34
Uniformed           7,844  
3.3 PLHIVs Who are Currently …

Viral load testing and suppression, All Ages ,9month 2015 EFY-Source –EPHI
97.0% 0.96712661908538
0.968
0.96629024102477 2
0.96513696193525
7 0.96475409836065
4 6
96.5% 0.96262740656851 0.96351504095467
0.96130162241887 6
0.96140350877193
9
0.96046159667045 0.95880754538652
96.0% 4

95.5% 0.95439847442169
0.94992278844032
7
95.0%

94.5%

94.0%
AA Afar Amhara Beni-Gumuz Defense Dire Dawa Gambella Harari Oromia Sidama SNNPR Somali National
3.3 TPT Initiation from Newly and TX-Curr
Region Tx_CURR,(Meg,2015) #/% TPT started from Tx_NEW TPT % started
Tx_CURR,(Meg,2015) (Meg,2015) started(Meg,2 TPT from
015) Tx_NEW

Addis Ababa 95,011 81,841 (86%) 477 322 67.5

Afar 4,143 3,667 (88%) 20 8 40.0
B/ Gumuz 4,121 3,592 (87%) 26 9 34.6
Gambella 8,801 7,148 (81%) 93 55 59.1
Harari 3,403 2,884 (85%) 9 1 11.1
Somali 1,362 1,180 (87%) 8 8 100%
Sidama 6,471 5,870 (91%) 47 32 68.1
SNNP 20,526 18,885 (92%) 178 112 62.9
Dire Dawa 6,979 6,432 (92%) 39 27 69.2
Oromiya 82,079 72,184 (88%) 394 254 64.5
SWE 6,444 5477(85%) 678 306 45.1
Amhara 139,256 120,386 (86%) 667 406 60.9
36
Tigray  
TPT Coverage among  
TX _ Curr =87% ( EMR)      
 PMTCT Service Coverage and MTCT Rate

National 12.04 85.91

6 2014 EFY MoH Anual Report
Addis ababa 100.36
Amhara 6.57 100.62 • MTCT rate 12% national – highest Sidama,
Tigray 8.51 95.01 Somali, Afar
Gamella 8.81 106.09  Half of MTCT is during breastfeeding
Harari 11.79 84.9
SNNPR 11.94 88.18
• Estimated HIV-positive PBFW who Received
Benishangul 13.33 83.09
ART–89%
Oromia 15.82 74.83  37% newly diagnosed & 63% ART clinic
Dire Dawa 15.99 81.28
26
• Poor performance on HEI diagnosis and
Affar 52.12
31.61
prophylaxis
Somali 35.03
Sidama 33.26
26.12
 virology test within 12 months – 62%
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0  Received ARV prophylaxis for 12 weeks
– 47%
eMTCT rate final (%) PMTCT Coverage  Cotrimoxazole prophylaxis – 58%

Low PMTCT coverage higher MTCT rate 38

 NSP Review – 2014 EFY Target vs Performance (2)
PMTCT, Care and 2014 EFY PMTCT, Testing2014 EFY
and Treatment
Treatment target NSP Target Achievement
MTCT Rate 7% 12%
HEI 12 Month virologic 87% 62%
Testing
HIV test Yield 1.5% 0.7
PLHIV know status (1st 95) 93% 84%
On treatment 95% 98%
(2nd 95)
Viral Suppres 95% 98%
(3rd 95)

39
 Treatment Cascade (All PLHIV and
Adults)
(Achievement of 95-95-95
98
Targets)
98
100.0
90.0 84.4
80.0
Percentage (Conditional)

70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0

1st 95 2nd 95 3rd 95

Source SPECTRUM 2022 40

 Treatment Cascade (Children and Youth)
(Achievement of 95-95-95 Targets)
99.2 100
100.0 92 93.5 91 90
90.0 82.5 84.7
80.0
70.0
60.0
50.0
40
40.0
30.0
20.0
10.0
0.0
15-24 Female 15-24 Male Children (0-14)

1st 95 2nd 95 3rd 95

• Case detection is a major challenge of treatment among children

41
Service delivery Platforms
Challenges
 Lack of standardized peer service
providers package, training, incentives,
and monitoring
 DICs are friendly to KPs but
 Limited scale and varying standards
 Largely donor-funded and only FSWs
 High cost (650,000 per month)
 Govt led DIC did not work
• KPP-friendly clinics – mostly
underutilized and heavily dependent on
incentives through SNS
 Only 57% have flexible working
hours and community outreach
 Limited use of virtual safe spaces
Recommendations
• Standardize and scale up Peer Providers
Program package, training, and incentives
• Scale up and standardize DICs
 Scale up CSO-led DICs
 Define standards for ART and Non-ART
DICs
• KPP-friendly clinics – serve a range of KPP
groups and improve their friendliness –
flexible working hours
• Introduce virtual service delivery platforms
42
Female Sex workers Program
• Relatively better in scale - DICs, KPP- Recommendations
friendly clinics, and peer outreach
• Develop guidelines/SOPs for mapping
Challenges and size estimation at the district level
• Lack of SOPs, job aids to conduct
district-level mapping and size • Improve the quality and scale of multi-
estimation session peer-based SBCC
• Limited quality of multi-session peer • Enhance targeting of virtual, home-
education sessions based, and new entrant FSWs
• Limited targeting
• Prevention, management, and Mitigation
 virtual, home-based, and new
entrants FSWs of GBV from clients and law enforcement
• High risk of GBV by clients and law • Reconsider the use of incentives – SNS
enforcement - Limited mitigation • Easy transfer out and transfer into
measures services for FSWs & Unique identifiers
• High repeat testing through the
incentive-based SNS HIV testing
• Mobility of FSWs and difficulty to ensure
continuity and adherence to services
44
Thank you!

45