Humana People to People Botswana 2016Year End Report HOPE Humana Program Submitted to: U-landshjelp fra Folk til Folk Norway
Map of location of Projects in the Program: Projects in the Program (from North to South): 1. HOPE Humana Francistown 2. HOPE Humana Palapye 3. HOPE Humana Kweneng 4. HOPE Humana South East 5. HOPE Humana Kanye 6. HOPE Humana Goodhope 7. HOPE Humana Mabutsane BACK GROUND Botswana has the world s third highest HIV prevalence, measured at 18.5% by the Botswana AIDS Impact Survey (BAIS IV), released in 2014. One in five in Botswana is HIV positive. The burden of infection remains titled heavily towards women and girls. The adjusted HIV infection (incidence) rate was 1.35%, down from 1.45% in previous BIAS III. The age group hardest hit are the people between 31 and 49 years of age. 41% are infected. This figure is high also because people survive longer due to the anti retroviral treatment. The 15-24 years of age have Page 2
managed to keep infection rate to 8%. But the trend is increasing. 30% of the populations don t know their HIV status. 63% of people with tuberculosis are also HIV positive and must be treated for both. PROGRAM HOPE Humana Program is a community based program which gives people hope, information and skills to prevent HIV infection and to prolong lives of people already infected. It reaches out to the people in deepest need through fighting shoulder to shoulder with the poor by using a people to people strategy. The program activities and interventions complemented government efforts by working at the grass root level, where health facilities cannot reach to. HOPE Humana seeks to also address people s vulnerabilities to HIV/AIDS and tuberculosis, poverty and gender inequalities. It also contributes to the improvement of gender-based responses and programming in HIV/AIDS, and OVC care and support. HOPE Humana program has worked in above most HIV/AIDS hard hit districts and covered most of the population since 2006. HOPE Humana Botswana has from in January to December reached 77,145 persons directly, either in conversations in their home, in support groups, in clubs, in workshops, in health lessons in clinics. The initial target was 93,752. HOPE Program activities are implemented according to the three elements of HOPE; Health Programs, Opinion forming Activities and Outreach activities. HEALTH SERVICES: HIV testing: Since October 2015 the HOPE Humana program expanded its mobile HIV testing in Goodhope, Southern and South East districts into home based testing and tuberculosis testing and care. This forms part of implementing the UNAIDS defined 90-90-90 vision as a way to eliminate all new HIV infection by year 2030 by working systematically on the entire cascade of care: The 1 st 90: 90% of all who are living with HIV must know it by getting tested. Research has shown that in many homes of HIV positive persons, there is a partner who never tested for HIV and is likely to be HIV positive. HOPE Humana collaborated closely with health facilities and received list of the following type of patients (index clients): People Living with HIV and AIDS, Women in Prevention of Mother To Child Transmission of HIV program, Orphans and Page 3
Vulnerable Children, People with Sexual Transmitted Infections and Tuberculosis patients. The program support people through risk reduction plans to change sexual risk behavior. In this way HOPE Humana managed to find a good percentage of people living with HIV, who didn t know and didn t dare to find out. The 2 nd 90: From testing HOPE Humana link those living with HIV virus to certain health facilities. HOPE Humana in three districts achieved that 95% of people living with HIV start treatment right away with Anti Retroviral Therapy (ARV s). This demands a strong referral system from Community health Worker to and health facilities and feedback systems to trace if the persons have started treatment. HOPE Humana gives peer support for treatment seekers. The 3rd 90: Demands that minimum 90% of people on ARV treatment achieve viral load suppression. This requires consistent adherence to the drugs regimen. In October 2016 the HOPE Humana Kweneng project got an opportunity to also follow this vision by HIV testing. In other projects people were counseled and referred for testing. 16,923 people were counseled and referred to HIV testing out of the intended target of 42,581. 8,277 people went through HIV testing out of a goal of 23,230. The targets were not reached, since NGO testing partners lost funding in most of the country, and people don t go to their health facility to test. Tuberculosis: Other HOPE Humana projects in Francistown, Palapye and Phikwe scaled up its work with mine workers, former miners and their families (key populations) to give them TB information, screen them for TB, TB sputum test those with symptoms, secure enrollment at TB treatment and create TRIOS to observe daily adherence to treatment. This emerged from a recognized need for a regionally coordinated response to the issue of tuberculosis and related illnesses in mine workers networks. HOPE Humana Projects in three districts informed and screened 3,525 key population people with a symptom questioner and taught infection control measures. 527 were tested for tuberculosis (sputum testing). 372 started TB treatment. 286 TB Trios were established to secure strict adherence to the drugs to get cured. Condom distribution: 519,501 condoms were distributed through during the door-to-door mobilization, campaigns, talk shows, and in condom dispensaries, shops, and tuck shops, in bars and in public offices. The program goal was to reach a target of 734,601 but there were not enough condoms imported to the country. The condom work was done to complement the health sector efforts. Condoms are the main effective method to prevent HIV and other sexually transmitted infections. People need to have easy access in high numbers. Community Care: HOPE Humana projects works closely with communities in providing support through counseling, psychosocial support as well as creating conducive environment for those with challenges in adhering to treatment. 632 TRIOS were formed by people living with HIV and Page 4
286 by tuberculosis patients, total 918 out of the goal of 1,915. A TRIO is a direct observed treatment group consisting of three persons. The person initiating AIDS treatment will disclose to two buddies who commit to see the person drink the tablets once a day and support in any other way necessary until the patient is comfortable with the treatment. Medical male circumcision: Botswana is not a country with a tradition for male circumcision, but Government has set a target of 60% of HIV negative men becoming medically circumcised (380.000 men). It is not easy to convince men to circumcise but HOPE Humana has mobilised 474 HIV negative men, who went through the operation (the target was 635). This happened by informing and mobilizing also their partners and families at home. Medical circumcision reduces risk of infection with 60%. HOPE Humana Projects worked hard to mobilize men to undergo circumcision. HOPE has succeeded to mobilize many young men as well. OPINION FORMING ACTIVITIES: HOPE Humana helped family members to form opinions as well as to take a number of steps to change. HOPE projects drew a long list of activities, lessons, workshops and events in all sorts of connections, initiating debates with participants. Many methods were developed to involve people to formulate their issues and give the right solutions. The projects gave target groups and stakeholders opportunities to share their concerns, discuss their views on health prevention behaviors, stigma, discrimination and treatment. People were reached in their homes, in youth clubs, in schools, in workplaces and in churches. HOPE Humana has taken great strides to advocate for the right to treatment. Risk reduction plan: The Outreach officers conducted door to door counseling and assisting people to think aloud about the risks of contracting the HIV and TB and 10,303 people made their personal reduction plan for behavior change. 5,851 people became compliant with their prevention plan to eliminate risk. They will have follow up visits to see how they are changing their behavior. Gender norms and gender based violence: Youth and adults are invited into debates on gender based violence, as it is a major factor for omitting protected sex. The projects also targeted Adolescent Girls and Young women, because some due to poverty move into sexual relations with men being older than them, and the girls fail to negotiate safe sex. HOPE Humana identified children, youth and adults who are abused of any type of domestic violence in the society. HOPE projects networks with relevant authorities in the districts for referrals for help. The projects have been together with 4,431 people in 10 hours discussions on mapping out Page 5
harmful gender norms and what is gender based violence. This is a very common treat to women and causes them to be affected by HIV. Out Reach officers move from bar to bar to mobilize men on protected sex, information on HIV and TB treatment and stop forcing their partners to have sex thereby infecting others with AIDS. OUTREACH ACTIVITIES: Through a systematic from door to door and one-on-one interpersonal communication and counseling approach HOPE Humana has reached individuals and referred those in need for assistance. This strategy has turned out to be the way of reaching people to changing their behavior. Today outreach is also about making follow up all those who tested and were referred for treatment, and follow up all those who entered into treatment to create good follow up support mechanisms to secure 100% stop of infection. During outreach activities the following topics were mostly discussed: HIV/TB Co-infection, repeated pregnancy for People Living with AIDSs, Gender Based violence, Sexual transmitted Infections (STI), multiple concurrent partnerships, correct and consistence condom use, ARV Adherence, Teenage Pregnancy, Safe Male Circumcision and delay of sexual debut and much more all needed in the fight against AIDS and in dealing with the consequences of the AIDS epidemic. Support groups for People living with HIV: The Outreach Programs include positive living groups, in which 564 people living with HIV supports each other. Lessons were conducted with support groups. Support groups are a very progressive movement and they discuss all related issues on HIV positive living. The support groups are assisted with lessons and discussions by HOPE staff and are helped to start vegetable gardens. Lessons were conducted with caregivers, volunteers and organizations on how to take care of the sick. Orphans and Vulnerable children: 443 OVCs were assisted to benefit available services (intended target 994). HOPE Humana staffs find problems accumulating in many homes where mothers have died of HIV. The grandmothers lost their husbands as well and try to take care of grant children with small means and having old people diseases themselves. HOPE Humana then assists with information, testing, referrals for treatment and economic assistance from social welfare as well as at times protection by the police and chiefs. Page 6
Food gardens: HOPE Humana has seen the need for people living with HIV to eat before taking HIV/AIDS treatment. This is a challenge for disadvantaged people. 179 backyard gardens have been established for families to produce food. Those advancing in production are assisted to start more profitable businesses or productions. HOPE activists: 2,102 people have been active in their communities as volunteers under HOPE. HOPE Humana projects managed to convince the districts to place youth who are in National Service in the HOPE project. Moreover 60 youth were attached and trained to work in the Out Reach activities in the villages where they are deployed. There are other volunteers such as interns from counseling colleges and universities bringing different important skills to the project. Therefore 1,211 people have been trained under HOPE, and the target of 2,579 was not reached. IMPACTS OF THE PROGRAM Gender Based Violence: People are able to speak out about their challenges affecting them as SASA gender norm discussion sessions is revealing these challenges and people are referred for counselling. This has led to less teenage pregnancies and more condom use. Behaviour Change: A large number of student at schools are showing change. E.g. their student who were using drugs (marijuana) and they have shared their testimony with rest of the school that they are no longer taking drugs after receiving one on one session with outreach officers at Humana. Safe male circumcision: During the health talks, circumcised men now take a stand in mobilizing other men for circumcision more especially young men. HIV testing: Many people in faraway settlements and villages have been tested, who never tested and knew their HIV status before. Also a high number of youth came for HIV testing. Knowing their status (the first 90) will make them more consistent to prevent transmission of the virus to others and make them start on ARV treatment in good time before the body deteriorates. 100% uptake to treatment: The fact that every person who are tested HIV positive can be followed up in their home to be mobilised for treatment and care has made an almost 100% uptake to treatment (the second 90). The People are mobilized and they are able to seek different health services in different health facilities in the district. Page 7
Collaborating with stakeholders gave the project platform to be seen in the centre of many as we are taking the services to people and making them accessible to the community at all times in the field and in the centre. The care program: Forming support groups and TRIO contribute to ensure that people are being retained on treatment. There are less treatment defaulters and better treatment adherence which is the turning point for not affecting others. Once a person s HIV viral load in the body is low due to the treatment, they will not infect their partners (the third 90). Index I. Project in Numbers II. III. IV. Case story Pictures Recommendations Page 8
PROGRAM IN NUMBERS TOTAL Name of indicator Goals up to now Achieved results 1 People directly reached 93,752 77,145 4 People mobilized for HIV Testing 42,581 16,923 5 People Counseled and Tested 23,230 8,277 6 People Organized in support Groups 5,330 564 7 TRIOs for ARV Adherence support 1,915 632 8 HOPE Activists 2,102 975 9 People reached with RRP 46,941 10,303 10 Compliant 34,357 5,851 OTHER - - 11 Backyard food gardens establish 614 179 12 Youths and Children in HOPE Activities 10,877 5,619 13 People trained under HOPE Program 2,579 1,211 14 Condoms Distributed 734,601 519,501 15 People screened & referred for TB testing 1,547 3,746 16 Orphans and vulnerable children assisted 994 443 17 People who got TB sputum test - 527 18 People starting TB treatment - 372 19 Trios established for TB patients - 286 20 Men who did safe male circumcision 635 474 Page 9
The above results compared to goals reflect 11 months, January to November, as data verification/ audit was done in early December. Comments to the results in the table: Result 1: HOPE Humana seems to not reach its targets. The fact is that many projects stopped using the household register for a period, due to a heavy amount of reporting tools from a partner, so HOPE cannot document black on white more people. Result 2 and 3: HOPE reached less people because of the change of priority in Botswana as a country to now focus on clinic client partner testing, and focusing on finding those who have never tested for HIV before. Moreover the targets were not reached, since NGO testing partners lost funding in most of the country except in the PEPFAR priority districts, and people don t go to their health facility to test. The fact is that the HOPE work play a more important role for the country than ever before. Result 4 and 5: The projects didn t reach the intended target due to the fact that another implementing partner was appointed to form the support groups and provide individual care, not HOPE in four out of seven districts. This will change next year where HPP is allowed to provide care. Result 6: When the projects have the tasks of community care, many activists will be involved to lead support groups and TRIO. Result 7: Botswana was in a year of drought and families could not afford to buy water for their gardens. Result 8: The target was set unrealistically high, and in four districts another partner was appointed to implement care for the HIV positive youth. Result 9: 1,211 people were trained. People to be trained under HOPE Humana programme were not reached due to higher demands to qualifications for the community health worker. So four of the project became more professionalized, and the projects could not manage to train the set target for people trained under HOPE. Result 10: Some Districts Health management Teams could not provide the sufficient number of condoms to the district. Result 11: HOPE Humana in 5 districts started a TB program in April 2016 and in November 2016. Many people were screened for TB and referred for further clinical investigation. Result 12: The project didn t reach the intended target because the target is too high. There is need to revisit the planning. Page 10
PROGRAM IN PICTURES The project leader reaching out a family member of a former mine worker in block 4 community. An Outreach Officer referring a client to test for HIV during mobile testing campaign in the township Coloured Page 11
A Community Health Workers providing counseling and testing in a household. HOPE Humana Goodhope introducing risk reduction plan to a couple Page 12
Community Health Worker is in process to HIV test a young man. Project leader doing condom demonstration in a barber shop Page 13
Maoto a Nong savings group had a good time of buying presents for the members at end of year from their fundraised funds. HOPE Humana Officer doing Condom distribution at Palapye bus rank Page 14
RECOMMENDATIONS Page 15
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SUMMATIVE EVALUATION REPORT OF THE REDUCING WOMEN S VULNERABILITY THROUGH INCOME GENERATING ACTIVITIES AND ENHANCING EMPOWERMENT IN MABUTSANE SUB DISTRICT PROJECT. Conclusion (cited page 10-11m): Guided by this methodology and related processes, the Consultant analyzed the feedback, observations and experiences of the different levels of informants to obtain an in depth understanding of the performance of the project in relation to the key questions. The following findings provide an overarching picture of the performance of the project and recommendations moving forward. Page 17
1. FINDINGS For ease of clarity, the findings are divided into four sub-sections, namely, general findings, findings on each result area, findings relating to broad aims of the project and sustainability. This categorization of the findings will assist in addressing the key questions to be addressed by the Summative Evaluation. 1.1 General Findings Overall, the project was very successful in delivering the targets in all the result areas. Furthermore, an assessment of the results articulated in all monitoring and progress reports demonstrates some consistency with evidence on the ground. There was no exaggeration of results or traceable overreporting. The facts and figures are consistent with evidence obtaining on the ground.however, Result Area 4 needed more time for the network to be established. This could probably have been accomplished would the project preparatory and commissioning processes not have been too elaborate and consumed some time that was earmarked for actual implementation of activities. The Consultant observes that this gap is nothing extra-ordinary and is characteristic of applied processes typical of many projects. The essence from the onset was not just to accomplish all the planned activities but to ensure that implementation delivers the intended benefits to the target people in a sustainable manner.in view of the project implementation period, what was achieved is quite significant and whatever is outstanding is practically and functionally on course. With the approved no cost extension, the project may need to focus on building those structures as they may be important for the sustainability of the momentum created by the project. There was more than ninety percent confirmation by stakeholders that the project was very successful in transforming their livelihoods positively. This was particularly so in terms of facilitating transformation in shifting attitudes and instilling a sense of responsibility by the beneficiaries to take concerted action to better their lives and creating and manipulating opportunities for better livelihoods. The general impression was that the GROW model is the best initiative ever to be experienced by the beneficiary communities in terms of creating opportunities through Income Generating Activities critical to transform their livelihoods. Furthermore, it had a huge impact in facilitating mindset change among the beneficiary communities as the new opportunities have helped the communities realize that they have a huge role to play in changing their lives instead of just looking up to government and other external agencies. In short, the GROW model gained the communities a new perspective of life modelled around community self-drive for improved livelihoods. The community gate-keepers of the beneficiary communities, including Village Development Committees and Chiefs generally felt that the GROW model should be core to the Village and District Development Plans and they will lobby the relevant Government authorities to ensure that the model is mainstreamed as a key strategy for rural development and livelihoods enhancement. The model and project in general, created a good platform for community rapport and engagement on many issues that are core to their general well-being and development. By Richard Magweregwede. Page 18
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CASE STORIES Living in isolation I met Botlhe, a 67 years old woman in Tswapong Ward in Otse village during my household visits. Before I could sit down she started raising her concerns regarding her boring life. The discussions turned to be what she has been waiting for. She has been living in isolation as she felt that people will look at her with a different eye (discriminate her), so she decided to live her own life. She stays with a child who is 18 months old who has been abandoned by his mother (Seganka) when he was only three months old. Botlhe lives under poverty datum line and cannot afford living a better life. She is HIV positive but explains that she did not get it through sex. She stated that she got infected by caring for her late daughter who was HIV positive as she did not use protection (gloves) when bathing her. She felt that by using gloves she will be discriminating or marginalizing her. During our discussions, Botlhe cried stating that Seganka sometimes comes to insult her, take food by vigor and sometimes beat her. All these things made her think of committing suicide. From the household visit Botlhe was then invited for dream building activity. During dream building, concerns were raised and everyone get to open up. Botlhe openly talked about her HIV status and what is bothering her in life, then the community intervened. Fortunately, the ward Councilor, Headman and police representative were present to hear what Botlhe presented. Referrals were made during the Dream building. The ward councilor volunteered to take her for Counseling, the ward Headman, a neighbor volunteered to always support her for health checks when ever in need, the police representative volunteered to meet the social worker, and call Botlhe and Seganka for counseling and reconciliation. Through SALT and Dream Building, Botlhe has a back yard garden for healthy eating and living happy. She now understands that she is not the only one who has problems. She is adhering to treatment and knows where to seek support whenever in need. N.B Botlhe and Seganka, not their real names Lee Special Poomore Page 20
Living in denial situation I am a lady of 29 years old born and raised in Moshupa village. I am not comfortable to disclose my name. I am going to tell you a brief story on how I have been helped by Tirelo Mmusi - Humana People to People Project staff who is working in Moshupa. I tested for HIV in 2009 and my result were positive. I didn t accept my status which made me feel so stressful and didn t have courage to tell people at home, my friends and people in the community about my status. I was blaming myself for being positive. I came to a decision that I will not go to any facility to enroll on ARV treatment. I was always asking myself question on how people in my community will accept my HIV status. I just decided that I will die for my own denial and leave the rest in trauma. From 2009 to 2016 being HIV positive and not interested in visiting health facility, It once happened that one day I met Tirelo Mmusi during him door to door mobilization and asked me if he can visit me at home to talk about health issues I replied MAYBE but at last we came to agreement since I wanted to know their motive behind this home visits. I used to see them going door to door but not understanding what they are doing in our homes. Tirelo visited me at home and started by introducing himself, the organisation he works and the reason why they are moving door to door providing messages on HIV prevention and encouraging people to test. At first I showed him an attitude that I m not interested my reason being I know my status. During our discussion this man had courage not to lose the case. He visited me on several occasions and I agreed to be tested for HIV and the results were positive. I disclosed everything to him about my life as I told him that I had been in denial because there was someone to blame for all this but now I have no choice, I will go for what is right to my health. Tirelo started to visit my house every day providing counselling until I find myself at the clinic. He was so supportive, courageous and now I m enrolled on ARV treatment. I thought my life has turned to be a night mare but with the support from Tirelo I reformed, I m now adhering to my treatment, attending ongoing counselling and I m who I am because of Tirelo. This are the people needed to serve the world. Thank you so much my brother keeps that spirit up. I m so thankful. Page 21