Strategies for Epidemic Control - FHI 360
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MEETING TARGETS AND MAINTAINING
EPIDEMIC CONTROL (EPIC) PROJECT
COOPERATIVE AGREEMENT NO.
7200AA19CA00002
Strategies for
Epidemic Control
EPIC’S MENU OF TECHNICAL
STRATEGIES TO ADDRESS KEY GAPS FOR
EPIDEMIC CONTROL AND SERVICE
DELIVERY CONTINUATION
OCTOBER 2020Preface
In 2020, the global response to HIV showed inequitable progress across countries and was rocked by the
COVID-19 pandemic. This document is meant to assist U.S. President’s Emergency Plan for AIDS Relief
(PEPFAR) teams to identify successful and innovative approaches for epidemic control of HIV that can be
applied flexibly across the cascade. The challenges presented by COVID-19 led to rapid adaptations and
advancements in several strategies, all of which will have tremendous value for epidemic control even
after the COVID-19 pandemic subsides. In this document, some strategies are noted as “hot
approaches,” meaning they are well suited to meeting current program challenges at this critical juncture.
What’s Hot in 2021:
Hot approaches assist projects to meet targets across the HIV services cascade and uniquely address
current and future challenges faced by HIV programs. They address the following themes:
Differentiated service delivery (DSD): Approaches that expand the ways clients can find, access,
and engage in HIV services across the cascade, such as decentralized drug distribution (DDD)
COVID-19 mitigation: Approaches that allow HIV programs to ensure uninterrupted access to
services in the COVID-19 context
Going online: Innovations that take key aspects of HIV service delivery online or to virtual
platforms
Last-mile: Solutions particularly well suited to countries that are nearly reaching their targets for
epidemic control, and must shift toward highly targeted approaches to reach 95-95-95
Self-care: Approaches that allow clients to become aware of, access, or use HIV services on their
own and with less engagement from health care professionals
Contact
For more information or to request assistance on any of the approaches described in this document,
please email Hally Mahler at HMahler@fhi360.org.EpiC: Technical Strategies Menu for Epidemic Control
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 3Technical Approaches
Prevention ................................................................................................................................ 5
Online Outreach and Marketing ....................................................................................................................................5
PrEP Rollout and Scale Up Support................................................................................................................................5
Sustaining and Improving Quality of VMMC Programs .................................................................................................6
First 95: 95% of People Living with HIV Knowing Their HIV Status ..................................... 7
HIV Self-Testing (HIVST) .................................................................................................................................................7
Enhanced Peer Outreach Approach (EPOA) ..................................................................................................................8
Safe and Ethical Index Testing .......................................................................................................................................8
Recency Testing .............................................................................................................................................................9
Engaging Men ..............................................................................................................................................................10
Second 95: 95% of People Who Know Their Status are on Treatment................................11
Decentralized Drug Distribution (DDD) .......................................................................................................................11
Enhanced and Virtual Case Management ...................................................................................................................11
U=U Awareness ...........................................................................................................................................................12
Case Profiling ...............................................................................................................................................................13
Motivational Counseling ..............................................................................................................................................14
Optimizing Pediatric and Adolescent Treatment.........................................................................................................14
Improving TB Service Integration for PLHIV ................................................................................................................15
Third 95: 95% of People on Treatment with Suppressed Viral Loads .................................16
Supporting TLD Transition ...........................................................................................................................................16
Multi-Month Dispensing of ART (MMD) ......................................................................................................................16
Improving Viral Load Testing Coverage and Suppression............................................................................................17
Strategic Information ..............................................................................................................18
DHIS2 Standard Tracker ...............................................................................................................................................18
Online Reservation and Case Management App (ORA)...............................................................................................18
Population Size Estimation, Mapping & Microplanning ..............................................................................................19
Using Geographic Information Systems (GIS) to differentiate and decentralize HIV services ....................................20
Enabling Environment ............................................................................................................21
Community-led Monitoring .........................................................................................................................................21
Quality and Stigma Free Services ................................................................................................................................21
Violence Prevention and Response .............................................................................................................................22
Safety and Security of Implementers ..........................................................................................................................22
Capacity Development............................................................................................................23
Capacity Development for Local Partners ...................................................................................................................23
Human Centered Design ..............................................................................................................................................24
Total Quality Leadership & Accountability ..................................................................................................................24
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 4Prevention
Online Outreach and Marketing
GOING ONLINE; COVID-19
Online outreach and marketing support HIV programs to reach new target audiences online that have
been traditionally hidden from physical HIV outreach and service delivery as well as improve case finding.
Programs receiving support for online outreach can include learning about online target audiences using
online surveys, social media mapping, and community engagement. Programs are then supported to
implement a set of tailored online outreach approaches including trainings and tools for social network
outreach (online outreach workers), social influencer outreach, and social profile outreach (online
targeted advertising). When used in combination with an online reservation and case management app
(ORA), programs can offer beneficiaries a self-care pathway for accessing HIV services, which can also
be enhanced with partnership with private sector HIV service providers, remote/virtual case management,
and online client feedback systems.
When to ask for our help:
When program beneficiaries, or unreached target audiences, use online and mobile platforms
When the program suffers from consistently low HIV case finding
When the program is limited from reaching clients physically due to COVID-19
Combine with:
ORA
Virtual case management
LINK electronic client feedback systems
Partnerships with private sector HIV service providers and creative/marketing agencies (examples
in Kenya, India, and Jamaica)
Human-centered design
Pre-Exposure Prophylaxis (PrEP) Rollout and Scale-up Support
While several countries have added PrEP to their HIV prevention package, many still require support for
rollout or scale-up. EpiC supports programs in several ways to address common PrEP rollout and scale-
up challenges, such as to develop relevant guidelines, tools, standard operating procedures (SOPs), job
aids, demand-creation materials, training and mentoring of service providers, and the introduction of
different delivery models for PrEP, including measures for ensuring adherence and continuation. EpiC
has also supported several country projects to adapt and use individualized screening tools to prioritize
the offer of PrEP to clients who need it most.
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 5When to ask for our help:
At initial rollout of PrEP programs
When country programs are seeking additional support for PrEP scale-up
When support is needed to address gaps across the PrEP cascade
Combine with:
Online outreach and marketing
ORA (for online booking of PrEP services)
HIV self-testing as entry-point for enrolling on PrEP
Index testing (PrEP for the HIV-negative partner)
Forthcoming biomedical prevention options such as injectable long-acting agents, vaginal rings, and
other HIV prevention interventions
Sustaining and Improving Quality of Voluntary Medical Male Circumcision
(VMMC) Programs
VMMC is an evidence-based prevention approach that can reduce HIV transmission. Many VMMC
programs are largely donor dependent and their transition to local partners can put program quality at
risk. EpiC has a wide range of approaches to help transition VMMC programs to local partners, including
developing low-cost results-based financing (RBF) that can improve both supply and demand-side
performance of health systems and other quality assurance approaches. EpiC has experience supporting
local partners to consider costing of services and pricing incentives, defining performance and quality
measures, aligning VMMC services to program and beneficiary needs, and consensus building and
stakeholder engagement. EpiC supports VMMC program quality by facilitating technical assistance from
experts on VMMC programing on a full range of approaches from the formation of and support for a
continuous quality improvement team, to site assessments, client feedback, and responding to adverse
events.
When to ask for our help:
When seeking to strengthen long-term financial sustainability of service delivery in a specific sector
When seeking support from local partners and ministries of health to deliver high-quality VMMC
services
Combine with:
Capacity development for local partners
Total quality leadership and accountability
Rapid review and remediation of programmatic obstacles
Community-led monitoring with LINK electronic client feedback
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 6First 95: 95% of People Living with HIV Know Their HIV
Status
HIV Self-Testing (HIVST)
SELF-CARE | LAST-MILE | COVID-19 | DSD
HIVST has shifted the paradigm for HIV testing, the first step in the HIV care continuum. EpiC supports
ministries and programs in developing effective strategies for HIVST, selecting priority populations with
the greatest testing and treatment coverage gaps, adapting HIVST distribution models to reach those
populations effectively, and designing appropriate delivery and support mechanisms to ensure linkage to
confirmative testing and treatment services (including through phone/message-based support and virtual
or local supervision). EpiC has developed the HIVST Operational Guide, a step-by-step tool for planning,
implementation, and monitoring of HIVST to guide implementers when designing effective and targeted
HIVST services aligned to the three pillars of mobilization, testing, and linking. See this HIVST brief and
quick reference guide for more details.
When to ask for our help:
When HIV testing service (HTS) programs fail to reach undiagnosed people living with HIV (PLHIV)
and have low HIV case finding
When ministries struggle to gain consensus on how to integrate HIVST into their strategy
When HIVST demand creation and communications are weak and ineffective
When programs are ineffective in tracking and linking self-test users to confirmative testing, care,
and treatment
When needing to maintain HTS while adhering to COVID-19 social distancing
When partnering with the private sector for HIVST kit distribution and delivery
Combine with:
Conventional HTS at the facility and community levels to enhance efficiency
Index-testing approaches to increase uptake of testing among index cases
Demand creation for PrEP services
Online outreach and marketing to create demand for HIVST
Online ordering and home delivery of HIVST kits using an ORA
Lessons from DDD for the decentralization of HIVST kit distribution and reporting results
Public-private partnerships (PPPs) with HIVST kit providers and distributors
Workplace HIV programs to reach high-risk men and key populations (KPs)
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 7Enhanced Peer Outreach Approach (EPOA)
EPOA complements existing peer outreach activities by using performance-based incentives to motivate
those not currently engaged in HIV services. The objective of EPOA is to provide HIV testing services to
“new” networks (typically used among KPs). The individuals in these networks may have never or rarely
tested, be at high risk of HIV acquisition, and have HIV case-finding rates higher than those accessing
standard testing. EPOA involves the selection of peer mobilizers by existing peer outreach workers who
are typically new to the program and can engage their peers to avail HIV testing (and other services).
Peer outreach workers and mobilizers both receive a modest incentive for clients they successfully
recruit. See this brief to explain the difference between EPOA, index testing, and risk-network referral
(RNR). EpiC supports programs to design and implement EPOA using a standard guide and then
leverages a specialized data management system with built in-visuals to analyze data on a weekly basis.
The frequent data analysis will continuously assess whether EPOA is meeting its objectives and target
population and can be used to saturate higher risk and higher infectious networks
When to ask for our help:
When an HIV program wants to broaden outreach to new networks not previously engaged in HIV
programs
When the program suffers from low case finding
When programs want a performance-based incentive method to complement the traditional
outreach approach to motivate saturation into “unreached” KP networks
Combine with:
Online outreach and marketing to facilitate EPOA using virtual channels
Virtual coupons and tracking of EPOA with an ORA
HIVST kit distribution through EPOA networks and/or PrEP mobilization
Total quality leadership and accountability
Safe and Ethical Index Testing
LAST-MILE
Index testing is a focused HIV testing approach in which providers work with individuals living with HIV
(index clients) to elicit their sexual or injecting partners, their biological children, or biological parents (if a
child is the index client) for HIV testing and counseling. EpiC supports HIV programs to implement index
testing through the development and deployment of stringent standards for safe and ethical index testing
to ensure informed patient consent, awareness and protection of patient rights, and monitoring, reporting
and response to adverse events. Screening and response to intimate partner violence (IPV) is also a
requirement within index testing. Screening will help determine if certain partners should be referred to
testing based on the risk of violence to the index case, and response strategies should be provided to the
individual reporting IPV. EpiC also supports programs to implement a Risk Network Referral (RNR) that
extends beyond index testing to offer PLHIV self-guided options to informally extend links to HIV testing
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 8and other services to a broader set of social- and risk-network members of PLHIV who have an elevated
risk of HIV infection. See this brief to explain the difference between EPOA, index testing, and RNR, as
well as this brief on EpiC’s approach to index and other network testing approaches.
When to ask for our help:
When existing index-testing approaches lack client safeguards and protections
When clients and community are concerned about the confidentiality and safety of participating in
index testing
When clients want options for notifying partners and helping them to know their HIV status
Combine with:
Community-led monitoring to collect incidents and adverse events related to index testing
Violence prevention and response to better respond to any adverse events related to index testing
ORA with an online and client-led approach to partner notification
Motivational counseling to improve acceptance of index testing, elicitation of contacts, and contact
acceptance of testing and treatment if HIV positive
Recency Testing
LAST-MILE
Rapid HIV recency testing is offered to all newly diagnosed PLHIV to help identify individuals who have
become HIV infected within the past year. The point-of-care antibody-based assays differentiate between
recent HIV infection — when the antibody response is immature — and long-term infections in which a
mature antibody response is measured by strong antibody avidity. It is more likely that people with recent
infections are part of ongoing transmission networks. Individuals with recent infection were recently
acutely infected and were recently in high-risk contact with at least one other person living with HIV who
was not virally suppressed. Targeting testing among the contacts of recently infected individuals therefore
could improve the capacity of programs to detect and treat previously undiagnosed individuals while
focusing prevention services on individuals facing the greatest infection risks. EpiC supports programs to
implement recency testing by helping to expand capacity to provide recency testing, support linkage to
confirmation of viral load as part of a recent infection testing algorithm, and profile the characteristics and
preferences of recently infected individuals. EpiC also helps programs apply this information to improve
the targeting of HIV testing and other services in networks more likely to feature active HIV transmission.
When to ask for our help:
When programs suffer from low HIV case finding and more targeted HIV testing is required
Combine with:
Case profiling of recently infected clients to routinely identify the distinguishing characteristics of
individuals with recent vs. long-term infections to help focus program efforts
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 9 Index testing to safely link risk contacts of recently infected individuals to HIV testing and relevant
treatment or prevention services
PrEP to prioritize offers to HIV-uninfected partners of individuals with recent infections
Engaging Men
EpiC supports programs for understanding men’s barriers and challenges related to HIV testing,
prevention, and treatment from their own perspective, and helps develop strategies and programs that
align with their needs and preferences. The EpiC approach involves deep stakeholder engagement in a
process of co-creation that begins with definition of the problem and carries through to evaluation of
interventions in order to increase ownership, feasibility, and sustainability. EpiC can support HIV projects
to gain insights from male target audiences, design new tailored interventions for men including large-
scale communications, provide technical assistance to assess and strengthen current programs, and
adapt male-focused models piloted and evaluated in other contexts.
When to ask for our help:
When programs are struggling to reach and retain men
When otherwise effective programs have hit a plateau and require new last-mile solutions
When other male-focused solutions are not cost-effective, and more efficient, scalable, sustainable
solutions are needed
When technical solutions have been identified but have been hindered by lack of alignment and
buy-in among key stakeholders
Combine with:
HIVST
Community-based ART
Enhanced and virtual case management
Human-centered design
Online outreach and marketing
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 10Second 95: 95% of People Who Know Their Status Are on
Treatment
Decentralized Drug Distribution (DDD)
DSD | COVID-19
DDD refers to the delivery of antiretroviral therapy (ART) outside of health facilities and can include
private sector and alternative pickup points. DDD channels can offer additional DSD options to clients
across a wider range of services. EpiC has experience supporting HIV programs to implement DDD
through community pharmacies, automated dispensing, and the private hospital model. EpiC models
these distribution channels according to client preferences. Scaling up DDD in the private sector has
been found to have epidemiological and economic benefits for clients, donors, and governments. EpiC
has experience (1) engaging with ministries of health, PLHIV associations, and implementing partners to
agree on the appropriate model and policies, (2) conducting client and provider assessments to obtain
additional feedback, (3) mapping to determine underserved areas and match ART sites to pickup
locations, (4) capacity building and preparation of DDD outlets, (5) setting up data sharing and inventory
management systems, (6) demand creation and service delivery, and (7) setting up monitoring and
evaluation systems. EpiC also developed an online and off-line app (DDD app) which HIV programs can
use to facilitate reporting between the hub facility and pharmacy or pickup locations, monitor stock levels,
and send reminders for appointments.
When to ask for our help:
When programs need help delivering medications or other commodities
When clients want to access their medication and services outside standard clinics and hospitals
When COVID-19 limits clients’ ability to access clinics and hospitals (see how DDD can address
disruptions related to COVID)
When programs cover underserved areas with long distances to health facilities
Combine with:
Multi-month dispensing of ART and PrEP
Enhanced and virtual case management
The DDD app to manage client referrals to DDD outlets/pickup points and facilitate reporting
Using a geographic information system (GIS) to differentiate and decentralize HIV services
Enhanced and Virtual Case Management
LAST-MILE | GOING ONLINE | DSD
Enhanced case management provides the support of case managers to clients in routine and long-term
care. This is particularly useful for clients after HIV-positive diagnosis through ART initiation, retention,
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 11and viral suppression, but it may also be adapted and applied to PrEP initiation and adherence support.
EpiC’s range of case-management approaches can help clients overcome structural and social barriers to
partner notification, ensure timely links to treatment, and help newly diagnosed or reengaged ART clients
establish and maintain long-term treatment compliance. There is usually one person who coordinates the
case-management process, either physically or virtually through an ORA, and draws on the team’s skills
to provide tailored and individualized support based on needs. EpiC supports HIV programs to consider,
build, and strengthen case-management systems, including through the use of guidance and training for
peer navigators, technical assistance for improving long-term adherence through the use of tailored
support packages, and leveraging virtual case-management applications and devices to support clients
remotely. EpiC provides technical assistance to programs and local partners to implement site- and client-
level assessments with age/gender disaggregation to derive specific strategies based on real-time data.
When to ask for our help:
When programs experience gaps in treatment initiation, retention, and/or viral suppression
When clients lack support for ART initiation and treatment navigation
When programs do not have mechanisms for reporting outcomes of clients who get tested and are
diagnosed as HIV positive
When client’s knowledge about ART and treatment as prevention (undetectable = untransmittable
[U=U]) is low
When loss-to-follow-up strategies need bolstering
Combine with:
ORA to manage and track cohorts of clients on ART and PrEP
Support groups for PLHIV
Support rollout of MMD and DDD of ART by coordinating delivery and pickup of larger quantities of
ART
Train peer navigators and case managers on motivational counseling to better understand client
needs and challenges and develop solutions
Educating clients on the benefits of improved treatment regimens such as tenofovir + lamivudine +
dolutegravir (TLD) and treatment literacy such as U=U
Undetectable=Untransmittable (U=U) Awareness
An overwhelming body of clinical evidence has established that someone living with HIV who is on
treatment and has an undetectable viral load cannot transmit HIV to a sexual partner (see more in this
technical brief). The global U=U campaign was launched to reduce shame and fear of sexual
transmission; reduce HIV stigma at the community, clinical, and personal levels (including self-stigma);
and result in increased demand for HIV testing and ART and encouragement of PLHIV to start treatment
early, remain adherent, and obtain their viral load results. EpiC has supported local partners to plan and
leverage a wide range of approaches to increase awareness of U=U among program beneficiaries and
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 12other stakeholders, including refresher training for peer educators, peer navigators, case managers, and
clinicians, and supporting large social media and demand-creation activities.
When to ask for our help:
When clients are unaware that a suppressed viral load prevents sexual transmission of HIV
When there is high stigma, including self-stigma, that limits uptake of HIV services among PLHIV
When clients’ fear of an HIV-positive test result leads them to avoid testing
Combine with:
Enhanced and virtual case management
Online outreach and marketing
Motivational interviewing
TLD transition to help clients reach viral suppression faster
Case Profiling
LAST-MILE
Case profiling involves taking a granular look at the characteristics that differentiate individuals who meet
certain HIV cascade criteria — such as being newly diagnosed, initiating HIV treatment, or achieving HIV
viral suppression — from those that do not. This can be used to optimize the focus and impact of
outreach and testing, as well as to identify common factors among clients who are lost to follow-up or
taking more time to reach viral suppression, thereby guiding efforts to triage clients into the right level of
support and saving resources and time for clients who do not want or need additional support. EpiC
supports programs to implement a structured approach to case profiling and facilitates rapid data use to
inform and target program efforts. Strategic information and program staff closely collaborate to generate
case-profiling dashboards that highlight key gaps in individual outcomes and program performance, and
that speak to actionable priorities for improvement.
When to ask for our help:
When countries are interested in implementing a more client-centered service approach that
identifies and addresses the differentiated needs of individuals facing greater risks across the HIV
cascade — from being newly or recently infected, to falling out of care pre- or post-ART initiation, to
not achieving viral suppression or having advanced HIV disease
Combine with:
Targeted HIV testing efforts such as EPOA, recency testing, and index testing
Viral load testing
Enhanced and virtual case management
Optimizing pediatric and adolescent treatment
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 13Motivational Counseling
A common concern of programs designed to reach, recruit, and retain clients in the HIV services
continuum is their ability to support clients to overcome individual barriers to change. EpiC conducts
training in motivational counseling to help address challenges frontline workers face in motivating clients
to make informed decisions that lead to sustained positive outcomes. It is focused on listening and
interpersonal communication skills that have been proven effective in behavior change programs in
several areas, including those involving risk behaviors related to sex, alcohol and drug use, HIV testing,
and treatment adherence. EpiC can improve the quality of HIV services by equipping peer educators,
peer navigators, outreach workers, and other frontline providers to employ motivational counseling during
interactions with clients, including during counseling related to risk-behavior reduction, HIV testing, index
testing, treatment adherence, and other HIV prevention and care behaviors.
When to ask for our help:
When programs experience gaps in HIV testing uptake, PrEP uptake, treatment initiation, retention,
and/or viral suppression
When programs want to improve the quality of counseling and behavior change communication
provided to clients by peer educators, outreach workers, peer navigators, case managers, and other
healthcare providers
Combine with:
Clinic and community-based prevention (including PrEP), care, and treatment services
Client-referral approaches, such as EPOA and index testing
Enhanced and virtual case management (including peer navigation)
Online outreach and marketing
Optimizing Pediatric and Adolescent Treatment
Pediatric and adolescent HIV care requires urgent attention and action across many country programs.
Areas of focus include early infant diagnosis, ART optimization, viral load testing coverage and
suppression, and collaboration with orphans and vulnerable children (OVC) services to optimize case
finding, retention, and viral suppression. EpiC supports programs to tailor and implement services
specifically for pediatric and adolescent populations. For pediatric care, policy assistance can be provided
to assist the introduction and scale-up of point-of-care HIV testing at birth (for programs with established
capacity for early infant diagnosis), which will support immediate initiation of ART. This can be combined
with strategies for returning to care and treatment those who are lost to follow-up. For adolescent care,
EpiC supports programs to adapt and implement a range of approaches such as family index testing, lay-
counselor-led support, and support for clients to disclose HIV status to their family (shown to be a strong
factor affecting ART initiation and retention). EpiC also provides technical assistance for youth and young
adult programming such as peer-based approaches, setting up follow-up and reminder systems tailored
to adolescents and youth audiences (e.g., through eHealth approaches like SMS), and training providers
on youth-friendly care.
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 14When to ask for our help:
When seeking to coordinate and collaborate between programs focusing on ART and those
focusing on OVC
When there are gaps across the care and treatment cascade for pediatrics and adolescents
Combine with:
MMD of ART to reduce the number of times clients (or their caregivers) must visit the health facility
to pick up refills
DDD to offer more convenient ways for clients (or their caregivers) to access ART
Enhanced and virtual case management tailored for youth or interaction through caregivers
Use of an ORA for young adults to find and access HIV services discreetly on their smartphone
Improving Tuberculosis (TB) Service Integration for PLHIV
Prevention, early identification, and treatment of TB, including prompt initiation of ART, are essential
interventions for reducing morbidity, mortality, and transmission risk among PLHIV. Therefore, HIV
programs need renewed focus around TB preventive therapy (TPT), TB case detection, TB treatment,
and ART initiation among all PLHIV. EpiC currently supports country programs in the implementation and
scale-up of these essential interventions and is able to expand this support to other country programs.
Therefore, in addition to supporting massive scale-up of TPT, including strategies for ensuring adherence
and completion, programs must be ready to support ministries of health to update their national guidelines
to reflect these new recommendations. Prompt treatment initiation among HIV/TB-coinfected individuals
and TPT are two priorities PEPFAR that require renewed focus from country programs.
When to ask for our help:
When programs need support for massive scale-up of TPT, including strategies for ensuring
adherence and completion
When countries need support to update their national guidelines to reflect new World Health
Organization (WHO) recommendations, especially those related to recently approved, shorter TPT
regimens
When support is needed for better integration of TB services into HIV programs
When support is needed for addressing gaps across the HIV/TB cascade
Combine with:
Enhanced and virtual case management to support clients on ART to engage in TB services
Online outreach and marketing to create demand for TB services
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 15Third 95: 95% of People on Treatment Have Suppressed
Viral Loads
Supporting TLD Transition
WHO recommends that countries transition all eligible patients to ART regimens that contain dolutegravir
(DTG) in place of efavirenz (EFV). DTG-based ART regimens are associated with fewer side effects, drug
interactions, and discontinuations; rapid suppression of viral load; and a high genetic barrier to resistance.
EpiC supports HIV programs to advocate for a more rapid transition to TLD, develop resources for
educating providers and clients on the benefits of TLD, track the number of clients who are eligible and
transitioned per facility, and collect data on health outcomes and people on TLD to share and disseminate
with stakeholders.
When to ask for our help:
When programs struggle to document and track the scale-up of transition to TLD regimes
When programs and ministries are limited to scale up TLD because of policy or program challenges
When serving KP individuals who may have multiple partners and/or have trouble adhering to EFV
and risk developing resistance
Combine with:
MMD of ART
DDD of ART
Enhanced and virtual case management to support clients through the process of transitioning
Multi-month Dispensing (MMD) of ART
LAST-MILE | COVID-19 | DSD
MMD is a form of facility- and community-based differentiated service delivery (DSD) in which individuals
who are stable on ART receive three months of medication or more at each visit, enabling their
appointments to be spaced at less frequent intervals. In the COP 2020 guidance, all individuals who are
clinically stable are required to be provided six months of MMD. It is also expected that 80 percent or
more of ART patients should have MMD available to them even if they are not official defined as “stable.”
The COVID-19 pandemic underlines the importance of offering MMD to clients to reduce the number of
unnecessary visits for ART refills. EpiC has supported several HIV programs to scale up MMD (including
six-month MMD [MMD-6]), particularly in the context of COVID-19 service delivery disruptions, helping to
maintain client access to ART and allowing them to stay at home. EpiC can help programs phase in MMD
for clients while safeguarding ART stock, and set up systems and teams to support clients to manage
their higher ART supply and schedule refill appointments, including in situations where drugs are
delivered to clients at home.
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 16When to ask for our help:
When COVID-19-related lockdowns limit client’s ability, safety, or interest to visit health facilities
frequently
When clients are stable on ART and do not require monthly facility visits
When programs need support with the scale-up of MMD-6
Combine with:
Enhanced and virtual case management to support clients remotely while they are not accessing
the physical health center as frequently for refills
Appointment spacing and fast-tracking approaches to minimize client traffic in health facilities and
reduce time spent at the health facility
DDD of ART, including through convenient pickup points, home delivery, and pharmacies.
Improving Viral Load Testing Coverage and Suppression
The goal of ART is to achieve viral suppression and stop further transmission. Therefore, viral load testing
is necessary to gather information on the proportion of PLHIV with viral suppression and helps to identify
those who will require additional adherence support. Gaps currently exist across the viral load testing
cascade in several countries, and HIV programs must develop appropriate strategies and approaches for
addressing these gaps. EpiC supports programs to develop relevant approaches to expand demand
creation and scale-up of treatment literacy efforts among PLHIV; design and implement innovative
approaches for sample collection at community-based sites, including the use of dried blood spots (DBS);
and train and mentor service providers on the use of viral load results for clinical management of PLHIV
and scale up of U=U messages. See the viral load suppression brief for more information.
When to ask for our help:
When clients are unaware of the importance of viral load testing and U=U
When programs face challenges collecting, transporting, and reporting results of viral load services
When there is low viral load testing coverage among clients on ART
When clients on ART are commonly unaware of their viral load results
When providers are unsure how to use viral load test results to provider tailored support to clients
Combine with:
Peer navigation
Enhanced and virtual case management
TLD transition
MMD of ART
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 17Strategic Information
DHIS2 Standard Tracker
KP clients served by HIV programs need continuous engagement throughout HIV prevention, care, and
treatment services. As such, it is important to track individuals longitudinally across the continuum of care
throughout the duration of program implementation to better understand the needs of clients, tailor
effective packages of services, and optimize program outcomes. Based on EpiC’s experience
independently developing DHIS2 trackers for KP programs in eight countries, the majority of the data
elements were found to be similar, yet the structure of data systems across countries differed, creating
challenges when analyzing results or mapping data to external databases. In response, EpiC developed
and advocates for use of a standard tracker for KP programs, including metadata that define a minimum
set of indicators for reporting, performance assessment, client management, and quality improvement.
EpiC provides technical assistance to help countries customize and configure the tracker to local country
contexts while ensuring a certain level of uniformity and data quality assurance across programs. The
metadata package can be easily downloaded and rapidly deployed, saving programs time, money, and
effort.
When to ask for our help:
When programs lack standard methods for tracking client engagement in HIV services across the
cascade
When community partners require standard systems for tracking individual clients
When programs lack unique identifier codes to confidentially track clients’ service access
When determining how best to customize and configure the tracker to the local context
Combine with:
Use of PowerBI for visualizing program results
Use of an ORA to allow clients to book services online on their own (results from which can be
reported on DHIS2)
Use of DHIS2 for aggregate reporting of Monitoring, Evaluation, and Reporting (MER) and custom
indicators
Online Reservation and Case Management App (ORA)
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An ORA is an appointment and client management tool with simple interfaces used by clients, service
providers, and program staff (e.g., outreach workers, case managers, and monitoring and evaluation
[M&E] staff). For clients, it allows them to assess their own HIV service needs and book services across a
range of partner providers. For HIV programs, it serves as an electronic referral system, real-time point-
of-care data collection tool, and case management system. Programs can use the ORA for client
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 18management, and it can complement other program monitoring tools such as DHIS2. Appointment
records are shared with clinics and case managers who have unique access privileges to track and follow
up with clients. Service providers report client arrivals and services provided during the appointment,
while case managers view client arrivals and contact clients to facilitate and report follow-up services. The
ORA captures important indicators to track performance of online outreach and marketing efforts in
addition to the most common PEPFAR indicators for prevention, HIV testing, ART and PrEP initiation and
retention tracking, and viral suppression. Data can be visualized in a variety of cascades and tables on
the ORA’s back end, as well as exported in Excel for cleaning, analysis, and reporting. HIV programs can
choose between designing and hosting their own ORA platform or joining the existing global ORA
platform called QuickRes.org, which is faster and cheaper to use but less customizable to country
context.
When to ask for our help:
For programs in settings where online outreach and marketing approaches will be important to
connect with program beneficiaries
When engaging private sector health service providers that want a simple way to report results to
the program
When offering a self-care pathway for clients to engage in HIV services on their own
When offering special HIV services for the online audience that are not well captured using other
tools (e.g., virtual consultations for HIVST ordering and delivery scheduling)
Combine with:
Online outreach and marketing
Virtual case management
LINK electronic client feedback systems (ORA automatically sends clients LINK survey via SMS)
Client referral approaches such as EPOA and index testing
Addition of new services and delivery method options such as HIVST and DDD
Partnerships with private sector HIV service providers (examples in Kenya, India, and Jamaica)
DHIS2 Standard Tracker
Population Size Estimation, Mapping, and Microplanning
HIV programs can benefit from several evidence-based approaches when designing and planning their
outreach and service delivery to meet population size and need. The same approaches can be used to
help programs realign their efforts to meet changing populations and risks. EpiC has extensive
experience supporting HIV programs to support population size estimation (PSE) and adapt and
implement programmatic “hot-spot” mapping and use results to plan targeted outreach teams
(microplanning). EpiC/FHI 360 can serve as a pool of personnel who can help projects initiate
implementation of PSE, mapping, and microplanning by setting up systems for training field staff,
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 19including developing, testing, and disseminating guidelines for updating KP site listings, population size
estimates, needs, and current access to essential services.
When to ask for our help:
At program start-up to plan the peer deployment and outreach approaches
At program start-up to train the frontline workers once the peer deployment plan is in place
When projects could benefit from updating their site listing and KP size estimates, removing inactive
sites and adding new ones that may emerge (e.g., annually or biannually)
When a new area of operation is identified which needs mapping and microplanning
Combine with:
DHIS2 Tracker used by frontline workers in hot spots to track coverage of outreach
Planning the size, number, and caseload for teams of peer educators and peer navigators
Social media mapping and quick online surveys to plan online outreach and marketing
Using Geographic Information Systems (GIS) to Differentiate and
Decentralize HIV Services
The latest geographic information system (GIS) technology allows HIV programs to answer detailed
questions regarding how and where HIV services should be differentiated and decentralized. EpiC
supports programs to combine program data and open-source secondary data (i.e., roads, terrain, highly
detailed population estimates) through spatial models to describe (1) where ART clients likely live across
the catchment area, (2) the travel time to reach the nearest clinics, (3) how travel time could be reduced
when new sites are placed, and (4) the best sites to decentralize services based on location, reduced
travel time, and available services. EpiC employed these spatial methods using ArcGIS software and
provided detailed results on secured interactive maps or as PDFs to then guide community teams on
what areas to focus on and prioritize for HTS and case identification based on clustering of HIV-positive
cases around hot spots.
When to ask for our help:
When program’s services are misaligned with the locations of target audiences
When programs have low case finding and need more targeted approaches
Combine with:
DDD of ART
Case profiling and recency testing to better understand chains of transmission by location
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 20Enabling Environment
Community-led Monitoring (CLM)
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CLM is when community service organizations (other community groups) gather quantitative and
qualitative data and observations about components of HIV services to support community accountability
and quality improvement. EpiC’s approach to CLM includes obtaining client feedback from multiple
sources, including through LINK electronic client feedback (short online surveys), community score cards,
and direct reporting of any adverse events to service providers, peers, or others. EpiC enhances CLM
with systems that support responding to adverse events reported through the CLM system. EpiC has
extensive experience implementing this range of approaches for CLM, including client feedback systems.
When to ask for our help:
When programs lack community oversight of HIV programs and services
When clients lack ways to provide feedback and submit complaints about services they receive
When mechanisms to escalate any issues to higher levels do not exist
When programs struggle to quickly and actionably use and respond to available client feedback
When program staff receive reports of violence or other adverse events and are untrained or unsure
how to respond to address and prevent future incidents
Combine with:
Index testing to offer clients a simple way to report adverse events or their experience
ORA, which can automatically send clients an SMS with a link to provide feedback (LINK)
Quality and stigma-free services with the Health4All health care worker training curriculum
Quality and Stigma-Free Services
KP sensitivity training provides health care workers with information about KPs and the importance of
working effectively with KPs for an effective HIV response. It also creates self-awareness about providers’
own biases or misunderstandings that may prevent them from offering quality, KP-friendly services and
helps them practice interactions that are nonjudgmental, supportive, responsive, and respectful. Health
care workers are also trained to provide the recommended package of services based on KP groups
served. See the Health4All curriculum as an example.
When to ask for our help:
When clients complain of poor service quality or stigma and discrimination at program service
providers
When providers request support to provide KP-specific care
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 21Combine with:
Community monitoring and LINK electronic client feedback
Violence prevention and response training among providers
Violence Prevention and Response
Due to the disproportionate burden of violence KP members face, the effectiveness of HIV prevention,
care, and treatment services can be compromised when violence prevention and response (VPR)
interventions are not implemented concurrently. In addition, PEPFAR requires service providers to ask
about and respond to disclosures of violence as a part of PEPFAR-supported index testing and PrEP
services. EpiC’s technical assistance supports HIV programs to integrate VPR into HIV programming
through trainings with various stakeholders to detect and respond to violence including with health
workers, community/lay workers, and law enforcement. Additional approaches and training guides are
available for law enforcement to reduce violence against KPs and program implementers, and to help link
people who experience sexual violence to health services such as post-exposure prophylaxis (PEP).
EpiC also can help programs meet WHO/PEPFAR requirements on the integration of violence detection
and response within index testing and PrEP services. See this package of violence prevention and
response resources.
When to ask for our help:
When violence occurs against clients or providers
When law enforcement officers’ actions make programming more difficult or directly abuse clients
When implementing PrEP or index testing
When the program has GEND_GBV targets
Combine with:
Safety and security for implementers
PrEP services
Index testing
CLM
Safety and Security of Implementers
Community-based organizations (CBOs) led by and/or serving members of KPs, especially in hostile
environments, experience chronic violence and other human rights violations, negatively affecting all
aspects of the HIV program cycle. A greater and more systematic investment is needed to identify and
address safety and security in almost every context where HIV programming for KPs occurs. The security
of implementing partners of KP programs can be improved by having each implementing partner
systematically assess their security gaps and strengths, attend a training to identify and prioritize their
security risks (such as arrests during outreach or data breaches), develop their own security plans
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 22according to existing capacity, vulnerabilities, and risks, and then receive small grants and technical
assistance to implement priority activities from security plans. See this safety and security toolkit.
When to ask for our help:
When security risks are heightened (e.g., preceding elections or during a backlash against the
lesbian, gay, bisexual, and transgender [LGBT] community)
For programs working in hostile environments (e.g., where KPs are criminalized or targets of
violence)
When engaging new KP-led or -serving CSOs that have not worked in HIV service delivery in the
past
Combine with:
CLM
Violence prevention and response
Capacity Development
Capacity Development for Local Partners
Capacity development for local partners focuses on enhancing organizational and management, strategic
information, and technical performance of individual organizations, as well as enhancing the systems
within which these organizations operate to better prepare them to effectively and efficiently manage
direct U.S. Government (USG) or other donor funding. EpiC’s technical assistance introduces new
knowledge or skills, or fine tunes systems and processes based on the results of capacity assessments,
the findings of regular performance reviews, or needs identified in other ways. Technical assistance can
take the form of coaching and mentoring, training, provision of tools and resources with associated
support, South-South transfer, online support, or other capacity development interventions. EpiC supports
capacity development in areas such as (1) organizational performance (e.g., financial management,
human resource systems), (2) technical performance (e.g., expanding and improving services, supporting
pivots in donor requirements), (3) strategic information performance (e.g., aligning data collection tools to
donor requirements, strengthening data quality systems), (4) reporting (effective communication of
programmatic achievements or responding to donor reporting requirements), and (5) sustainability
(supporting diversification of funding sources for local partners). EpiC has supported local partners to
transition to direct USAID funding, identify other sources of funding for a larger donor base, strengthen
programming, and grow their ability to analyze, adapt to, and influence their environment. See this brief
on EpiC’s approach to local partner capacity development.
When to ask for our help:
When local partners identify a gap in performance (organizational systems, strategic information
systems, or technical gaps) affecting the ability of the CSO to achieve organizational goals
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 23 When local partners are ready to transition to direct USG funding or strive to diversify their funding
base
When a local partner has transitioned to direct funding but may be in need of additional mentorship
to better manage funding and achieve performance goals in organizational, strategic information, or
technical areas
Capacity development can be combined with any number of program activities listed in this
document.
Human-Centered Design (HCD)
HCD is a collaborative, team-based problem-solving approach that provides creative methods for deeply
understanding human behavior to develop new ideas and solutions directly for and with the intended end
user or beneficiary. In broad strokes, the approach consists of three phases: (1) understanding context
and users, (2) translating insights into solutions, and (3) experimenting and prototyping a set of possible
solutions prior to implementation. EpiC uses HCD to address barriers and bottlenecks to service uptake
across the cascade by placing people at the center of the problem-solving process and allowing them to
co-design solutions to address issues they are facing.
When to ask for our help:
When there is an identified program performance gap that requires new, creative, client-centered
solutions
When programs need to adapt interventions, service delivery approaches, and product introduction
strategies to the local context or to better meet the needs of a specific population
HCD can be combined with any number of program activities listed in this document.
Total Quality Leadership and Accountability (TQLA)
EpiC deploys a TQLA approach to close gaps toward achievement of targets across the HIV cascade.
The TQLA approach — also called “surge technical assistance” — has three core elements: adaptive
leadership, situation room meetings, and performance-improvement monitoring. Together, they
strengthen the capacity of program managers and health care workers to use data for planning, adopting
local solutions to program weaknesses, and requiring accountability. TQLA supports leaders to target
resources to sites with greatest needs and enables attainment of results within reasonable timeframes.
FHI 360 has used the TQLA approach to improve the performance of several HIV programs, including in
Nigeria, Zambia, Burundi, Kenya, and Ethiopia. In Nigeria, the approach was recently deployed in six
USAID-supported projects across 10 states, enabling the programs to surpass targets for client retention
on ART and viral suppression.
When to ask for our help:
When there is an identified program performance gap
When needing to identify and document root causes to guide corrective action
2021 TECHNICAL STRATEGIES MENU FOR HIV PROGRAMS 24You can also read
