FY 2015 Angola Country Operational Plan (COP)

46 Pages·2015·1.22 MB·English

FY 2015 Angola Country Operational Plan (COP)

The following elements included in this document, in addition to “Budget and
Target Reports” posted separately on www.PEPFAR.gov, reflect the approved FY
2015 COP for Angola.

1) FY 2015 COP Strategic Development Summary (SDS) narrative
communicates the epidemiologic and country/regional context; methods
used for programmatic design; findings of integrated data analysis; and
strategic direction for the investments and programs.

Note that PEPFAR summary targets discussed within the SDS were
accurate as of COP approval and may have been adjusted as site-
specific targets were finalized. See the “COP 15 Targets by Subnational
Unit” sheets that follow for final approved targets.

2) COP 15 Targets by Subnational Unit includes approved COP 15 targets
(targets to be achieved by September 30, 2016). As noted, these may differ
from targets embedded within the SDS narrative document and reflect final
approved targets.

Approved FY 2015 COP budgets by mechanism and program area, and
summary targets are posted as a separate document on www.PEPFAR.gov in
the “FY 2015 Country Operational Plan Budget and Target Report.”
Country Operational Plan (COP) 2015
Strategic Direction Summary
Angola
Table of Contents

Goal Statement
1.0 Epidemic, Response, and Program Context
1.1 Summary statistics, disease burden and epidemic profile
1.2 Investment profile
1.3 Sustainability Profile
1.4 Alignment of PEPFAR investments geographically to burden of disease
1.5 Stakeholder engagement

2.0 Core, near-core and non-core activities for operating cycle

3.0 Geographic and population prioritization

4.0 Program Activities for Epidemic Control in Scale-Up Locations and Priority Populations
4.1 Targets for scale-up locations and priority populations
4.2 Priority population prevention
4.3 Voluntary medical male circumcision (VMMC)
4.4 Preventing mother-to-child transmission (PMTCT)
4.5 HIV testing and counseling (HTC)
4.6 Facility and community-based care and support
4.7 TB/HIV
4.8 Adult treatment

5.0 Program Activities to Sustain Support in Other Locations and Populations
5.1 Sustained package of services and expected volume in other locations and populations
5.2 Transition plans for redirecting PEPFAR support to scale-up locations and priority populations

6.0 Cross-cutting Support Necessary to Achieve Sustained Epidemic Control
6.1 Laboratory strengthening
6.2 Strategic information (SI)
6.3 Health system strengthening (HSS) – clear linkages to program

7.0 USG Management, Operations and Staffing Plan to Achieve Stated Goals

Appendix A- Core, Near-core, Non-core Matrix
Appendix B- Budget Profile and Resource Projections

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Goal Statement

The goal of PEPFAR Angola is to:
Close significant data gaps, beginning with the DHS+, that will enable the Government of the
Republic of Angola (GRA) to better understand, implement and monitor progress towards
epidemic control in Angola and;
Develop best practice models in Luanda that the GRA can take to scale by improving the quality
of clinical services for PLHIV in nine select high yield facilities through intensive mentoring,
supportive supervision and enhanced technical assistance to address the gaps in the HIV
cascade and by intensifying efforts to reach and link Key Populations (KP) who are
disproportionately affected by HIV, through the cascade of care in selected sub-national units
(SNUs).
The first step in achieving epidemic control is to better understand the Angolan HIV epidemic.
PEPFAR is partnering with the GRA to complete its first-ever nationwide demographic health
survey with biomarkers (DHS+) starting in August 2015 and ending in FY 2016. PEPFAR will
conduct three Biobehavioral Surveys (BBS) with size estimation to: a) identify HIV risk factors b)
provide an estimate of HIV prevalence among men who have sex with men (MSM), and c)
provide an estimate of HIV prevalence among female sex workers (FSW). These surveys will
inform further geographic prioritization to improve impact of KP interventions. The results of the
FY 2015 military-based SABERS survey will also be finalized. SABERS will produce HIV
prevalence and risk behavior data to allow for more targeted military programming. PEPFAR
Angola will support the implementation of an electronic longitudinal information system (SIS) at
the facility level to facilitate effective tracking of continuum of care activities and to optimize data
flow and communication between patient registration, testing, laboratory, and pharmacy.
The second step is to improve treatment for PLHIV. PEPFAR Angola will assist the GRA to
transform nine clinical sites in Luanda Province into ‘model of service’ sites that will consist of
replicable health systems for HIV care and treatment. Based on international best practices,
PEPFAR implementing mechanisms will provide facility level, intensive mentoring, supportive
supervision and other services directly related to PEPFAR goals. To ensure quality
implementation, acceptance of the model, and effective monitoring, PEPFAR will move into the
selected sites in a phased approach beginning with an initial three clinics in the first quarter,
three more in the second quarter and the remaining three clinics by the third quarter of FY16.
Order of implementation will be determined in part by results of the FY15 baseline assessments,
size of the clinics, and GRA input. Strategic laboratory and diagnostics strengthening will
continue with a focus on CD4 and viral load. Supply chain management will continue at the
above-site levels but PEPFAR will provide direct technical assistance only to select clinic-based
pharmacies to create model of pharmacy management.

PEPFAR Angola will improve MSM and FSW testing and referral outcomes by focusing on
targeted community outreach activities and referral to key population-friendly care facilities in
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three municipalities (eight communities). Interventions will be aimed at improving identification,
testing, and linkages to care & treatment, adherence and retention.
The nine clinical sites, excluding the military, will be in three municipalities within Luanda
Province. Approximately 30 percent of Angola’s population resides in Luanda Province; it is
where the majority of PLHIV reside, and it is also where the largest HIV testing hospitals are
located. In addition to the nine model clinical facilities and eight community sites, PEPFAR will
also work in 14 above-site locations. PEPFAR Angola will provide limited technical assistance
to government institutions to ensure financial sustainability of care and treatment models.
In Angola, quantifiable outputs and outcomes are expected by the end of the COP year of
implementation under this consolidated and refocused PEPFAR approach. Targets have been
set following a modified version of the 90-90-90 model that will allow a significant increase in
PEPFAR’s impact under the parameters of a technical assistance country. PEPFAR Angola is
confident that this new pivot in strategy will not only produce quantifiable results but will also
make the best use of resources and thereby assist Angola in its effort to contain the HIV/AIDS
epidemic.

1.0 Epidemic, Response, and Program Context
1.1 Summary statistics, disease burden and country or regional profile
Quality data that can be used to inform health programming in Angola is limited. There are no
reliable population-based HIV surveillance data or other health data available to inform planning
efforts. HIV interventions have been based on limited and inconsistent program data from the
National AIDS Program (INLS), HIV sentinel site surveillance at antenatal clinics (ANC), and/or
estimates from UNAIDS Spectrum projections (generated from those program data and ANC
sentinel surveillance estimates).
Angola is thought to have a generalized, heterosexually-driven, HIV/AIDS epidemic with an
adult prevalence of 2.42 percent. The 2014 preliminary Spectrum projections show there are
305,382 (242,189 adults [15-49] and 31,301 children) people living with HIV (PLHIV). Of those
PLHIV, an estimated 180,253 (59 percent) are in need of antiretroviral treatment (ART). The
ART coverage in HIV-infected adults was estimated to be 26.3 percent (72,066 adults on
treatment). Coverage for HIV-infected children was 14.7 percent (4,600 children receiving ART).
Adult ART is available at 155 clinics nationwide, pediatric services are available at 136 sites.

In Luanda Province, there are an estimated 91,560 (82,441 adults 15-49 and 9,119 children 0-
14) PLHIV. Angola records the number of HIV positive tests, rather than the number of HIV
positive individuals making it difficult to determine an accurate percentage of persons in care
and on treatment. In 2014, there were 18,242 (11,994 adults 15-49, 2,643 children 0-14, and
3,605 pregnant women) recorded HIV positive test results. In the same year, 17,341 (10,288
adults 15-49 and 7,053 children 0-14) PLHIV were enrolled in care and 9,476 (6,121 adults 15-
49 and 3,355 children 0-14) PLHIV were initiated on treatment.
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In 2014, approximately two-thirds of the estimated 1,146,985 pregnant women utilized public
clinics, however less than 50 percent (545,958) were tested for HIV highlighting a gap between
national policy established in 2014 and day-to-day reality. Of those tested, 1.94 percent
(n=10,606) were HIV positive. Overall, HIV prevalence in pregnant women has remained stable
between 2-3 percent since 2002. The median HIV prevalence of the 36 sites participating in the
biennial ANC HIV sentinel surveillance was 2.24 percent.

Key populations have not traditionally been a focal population for the GRA. To date, there are
two recorded HIV prevalence studies that have been completed including a 2010 MSM BBS in
Luanda Province and a 2009 BBS among women engaged in transactional sex in Cunene
Province. Both were limited in geographic focus and results from both have been critiqued.
Utilizing global peer-reviewed literature on population estimates (2.0 percent MSM [Caceres,
2008] and 2.2 percent FSW [Vandepitte, 2006]) the number of MSM is estimated at 106,231
nationally and 28,970 in Luanda Province. The number of FSW is estimated at 124,540
nationally and 32,446 in Luanda Province. A 2008 UNAIDS report showed FSW HIV
prevalence at 23.1 percent in Angola and peer-reviewed literature (Beyrer, 2008) combined with
a general population male prevalence of 1.99 was used to calculate MSM prevalence of 7.22
percent. Using the prevalence estimates, FSW PLHIV is estimated to be 28,644 nationally and
7,463 in Luanda Province and MSM PLHIV is estimated to be 7,649 nationally and 2,086 in
Luanda Province.
The HIV response in Angola is guided by the National HIV and AIDS Strategic Plan (PEN-IV), a
four-year (2015-2018), multi-sector framework developed to help achieve the national priorities
in the fight against HIV and AIDS. The PEN 2015-2018 strategic plan aims to increase ART
coverage by 2018 to 90 percent in pregnant women, 45 percent in adults, and 80 percent in
children.

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Figure 1: Positive test (percentage), INLS, Angola 2014, by province
Positive Tests by Province,
Angola 2014
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The key interventions, which need to be implemented in Angola to stem the spread of HIV,
include (1) increased targeted HIV testing for key populations and other priority populations, (2)
quality ART service access and retention (including improved adherence monitoring and a
decrease in loss to follow up) for all those who are eligible, and (3) promotion of HIV
interventions in KP after completion of size estimation and BBS. Gaps in the continuum of
response cascade are evident. For example, HIV testing is still inadequate. At least a third of
PLHIV are estimated to not know their status. Furthermore, routine external quality assurance of
point of care HIV and CD4 testing is limited. Lack of viral load testing to assess adherence and
effectiveness of ART has been identified as a key bottleneck in improving treatment outcomes
and retention. Data gaps are a huge challenge, in particular for monitoring of ART adherence
and retention. Other potential hindrances to the GRA’s success in HIV epidemic control include
the end of The Global Fund (GF) grant in 2014 (although a new GFATM HIV concept note has
been submitted). There will be a gap in GF financing to GRA in 2015. The impact of the drop in
oil prices on budget support provided for HIV/AIDS by the GRA is not yet clear, but there is
already a reduction in funding for capital expenditures in health.
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Table 1.1.1 Key National Demographic and Epidemiological Data
Total (all) <15 15-49
Source, Year
Female Male Female Male

N % N % N % N % N % 2014 unless noted
Total Population 22406006 100 5232996 23.4 5296081 23.6 5050458 22.5 4960392 22.1 UNAIDS
Prevalence (%)15-49 2.42 NA NA 2.84 1.99 spectrum
AIDS Deaths
12125 1528 1569 4226 3247 spectrum
(2014)
PLHIV 305382 15499 15802 143337 98852 spectrum
Incidence (15-49)
0.24 NA NA 0.28 0.20 spectrum
(2014)
New Infections
28872 spectrum
(2014)
Annual births 950179 spectrum
% >= 1 ANC visit 649,594 68.45 NA -- NA -- Nat’l Reprod. Prog. Final Report, 2013
Pregnant women
19187 68.8 spectrum
needing ARVs
Orphans (maternal,
114195 NA NA NA NA spectrum
paternal, double)
TB cases (2013) 60,807 500 300 25,648 34,359 GRA TB Report-2013
GRA TB Report-2013
TB/HIV Co-infection 2,667 11* NA -- NA -- NA -- NA --
*24,239 (tested/HIV)
UNAIDS, WHO 2007 Circ estimates for
Males Circumcised 6,199,454 90 NA -- 6,199,454 90
Angola applied to current male 15+ pop
Key Populations
Total MSM 106,231 2.0 Caceres 2008 (Est – Africa)
MSM HIV
7,649 7.22 Beyrer(OR3.8)/Spectrum 1.9 Male Prev
Prevalence
Total FSW 124,540 2.2 Vandepitte 2006 (Est Africa)
FSW HIV Prevalence 28,644 23.1 UNAIDS 2008, Angola
Total PWID --- ---
PWID HIV
--- ---
Prevalence
Priority Populations
100,000 1960 2 96,040 98 IRB submission for SABERS 2015
Military
* NA – not available
Table 1.1.2 Cascade of HIV diagnosis, care and treatment (12 months)
HIV Testing and Linkage to ART -
HIV Care and Treatment
2014

Retained
Population Diagnosed
HIV Total On on ART Viral Tested Initiated
Size In Care HIV
Prev PLHIV ART 12 Suppression for HIV on ART
Estimate Positive
Months
(#) (%) (#) (#) (#) (#) 12 Months (#) (#) (#)
Angola
Total 22,405,890 2.42 242,189 34,536 14,625 12,400 --- 1,001,441 46,800 14,625
population
Luanda 15-
2,915,442 2.83 82,441 10,288 6,121 103,882 11,994 6,121
49
Luanda 0-
3,074,694 9,119 7,053 3,355 16,517 2,643 660
14
Luanda Incl. in Incl. in Incl. in
Pregnant 310,979 2.42 15-49 15-49 15-49 125,287 3,605 3,043

Women above above above
Luanda

MSM (15- 28,970 7.22 2086

49)
Luanda
FSW (15- 32,446 23.10 7463

49)
Luanda TB 21,263 11 2,339

Angola
100,000 3.5* 3,500* 10,376 363*
Military
*MSM, FSW, and Military numbers are estimates
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1.2 Investment Profile
From 2011-2014, the GRA, through INLS, increased funding from 58 to 72 percent of the total
funding allocated for the HIV/AIDS response. The percentage provided by the GRA is actually
higher when expenses for HIV/AIDS activities outside the INLS budget envelope are taken into
account. With decentralization in Angola, salaries at the provincial and municipal levels are one
of the largest expenditures outside of INLS.
PEPFAR is the only bilateral program that substantially supports the Angolan HIV/AIDS
response. At a budgeted $17,700,000 per year, PEPFAR’s contributed expenditures were
roughly 22 percent of the total HIV/AIDS national program budget for 2013 and 2014. Other
multinational programs through the United Nations contribute about $1 million per annum, or
less than one percent of the estimated total HIV/AIDS national program budget.
The Global Fund has historically been a key donor partner to the GRA and was the second
highest funder after the USG. The Global Fund Prime Recipient, UNDP, ended activities in
December 2014. A concept note, based on the new funding mechanism, was submitted in April
2015. If the concept is accepted and approved in a relatively quick timeframe, Global Fund has
stated that it would expedite payment. Therefore, the earliest that Angola can receive funding
from the Global Fund would be third quarter 2016. The new funding request to the Global Fund
involves procurement of medications and testing supplies, areas that until recently were not
thought to be supported in the next round. As shown in table B, the GRA finances the largest
percentage of care and treatment which involves procurements. External donors have
historically supported prevention activities.
The predominant issue facing PEPFAR’s role in support of achieving epidemic control in Angola
involves the macroeconomic instability and subsequent revenue uncertainty given sharply
declining oil prices internationally, and limited external donor investment. Angola’s oil industry
accounts for about 50 percent of GDP and 80 percent of tax revenues. The 2015 GRA budget
was revised down in February 2015. Estimated revenue fell from $39 billion to $25 billion while
gross expenditures fell from $48.7 billion to $32.7 billion in the revised budget. The exact
percentage has not officially been released. Although much of the health sector budget seems
to be largely unaffected in 2015, capital projects have been downsized, postponed or
eliminated. This could affect access to health services in some areas of Angola. To date, the
GRA has not stated whether it will revise the budget in the National Health Development Plan—
long-term strategic guiding document.
If macroeconomic instability continues, the HIV/AIDS program could be compromised, as
budget responsibilities will rise substantially. Increased linkages of PLHIV to care, treatment
and other HIV/AIDS services could strain the national budget and compromise the life-saving
services such as life-long ART. Risks to success for PEPFAR Angola include, but are not
limited to: GRA’s inability to procure increased supplies of drugs and commodities, GRA’s lack
of ability to plan and execute strategic information for monitoring and evaluations, and
continuing downward trend of external donor investment in Angola.

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