Eastern and Southern Africa

This document evaluates the Expansion and Scale-Up of HIV-Sensitive Social Protection in Eastern and Southern Africa initiative, implemented by UNICEF in Malawi, Mozambique, Zambia and Zimbabwe from 2014-2018 with support from the Dutch government. It assesses the extent to which the initiative met its objectives and achieved the expected results and documents the successes, challenges and lessons learned in the implementation.

Under the initiative, UNICEF Eastern and Southern Africa Regional Office (ESARO) and UNICEF Country Offices provided technical assistance to the four priority countries, and documented cross-country learnings. Activities under this initiative differed in their design and execution, allowing for adaptation to country contexts. In Malawi, activities focused on monitoring and evaluation of the National Social Support Policy; designing and implementing a system to refer cash transfer beneficiaries to HIV-related social services; and creating demand for HIV services among adolescents. In Mozambique, activities focused on providing policy-level support to the operationalization of the new social protection strategy, strengthening community-based and statutory case management, and conducting social protection fairs. In Zambia, the Government and UNICEF evaluated and scaled up a package of services that aims to increase the utilization of HIV services by adolescents. In Zimbabwe, the initiative focused on strengthening the child protection case management system and ensuring linkages between the country’s flagship cash transfer programme and HIV-related services, by using payment days to deliver services. In addition, the initiative’s regional component, led by UNICEF ESARO, focused on documentation and dissemination of best practices and overall technical assistance to the country offices involved.

This review provides a conceptual framework for HIV-sensitive social protection policies and programmes and review the impact of social protection on HIV prevention and treatment outcomes in addition to social and economic care and support. It further provides recommendations for achieving core HIV impacts, comprehensive approaches, and expanding and sustaining HIV-sensitive social protection. 

Building on previous summaries, this brief summarizes the current evidence and lessons learned from the Transfer Project after more than a decade of research on cash transfers in sub-Saharan Africa.

Since 2009, the Transfer Project has generated rigorous evidence on the impacts of cash transfers in sub-Saharan Africa (SSA) and has supported their expansion. It aims to provide evidence on the effectiveness of cash transfer programmes, inform the development and design of cash transfer policy and programmes, and promote learning across SSA on the design and implementation of research and evaluations on cash transfers. The Transfer Project is a collaborative network comprising UNICEF (Innocenti, Regional and Country Offices), Food and Agriculture Organization of the United Nations (FAO), the University of North Carolina at Chapel Hill, national governments and researchers. 

Building on research findings and effective interventions in low-and middle-income countries, this policy brief identifies key risks, including bullying and stigma, and facilitators, such as positive parenting and social support, that influence pathways between mental health and HIV outcomes for adolescents. It is part of a broader series that aims to support the translation of research into improved adolescent sexual reproductive health and HIV programming.

Good mental health and psychosocial wellbeing is especially important for adolescents during their transition to adulthood. It can support resilience and help initiate healthy behaviours that shape long-term positive health outcomes. Evidence shows that adolescents living with HIV are more likely to experience mental health challenges compared to their peers who do not have HIV. Poor mental health outcomes have been linked to low rates of adherence to life-saving antiretroviral treatment (ART) and retention in care.  Understanding risk factors and protective factors that influence mental health and ART adherence amongst adolescents is critical for effective programming. Within eastern and southern Africa, there is great momentum to identify and scale-up interventions that address mental health and improve treatment, care and support for adolescents living with HIV.

This implementation brief examines the current efforts in eastern and southern Africa to accelerate and scale up evidence-based PrEP delivery platforms for adolescent girls and young women. The brief provides current knowledge and builds on WHO guidance to provide key considerations for implementation, including driving demand and improving quality, as well as focus on wider combination prevention and integration agendas.

Adolescent girls and young women (AGYW) remain disproportionately affected by HIV in eastern and southern Africa, however, they face many personal, social and structural barriers to access, uptake and use of traditional HIV prevention methods. Oral Pre-exposure Prophylaxis (PrEP) is proven to be highly effective as an additional prevention choice for reducing the risk of HIV acquisition, but the current demand for PrEP by AGYW is low with suboptimal adherence.

Within the region, there is currently great impetus to address these challenges and scale up PrEP for AGYW. A critical aspect of this is to leverage the learnings and evidence from implementation of how to improve the demand and quality of PrEP programming for this population. Improving the Quality of Pre-Exposure Prophylaxis Implementation for Adolescent Girls and Young Women in Eastern and Southern Africa is informed by knowledge and lessons learned emerging from a virtual thank tank and webinar convened by UNICEF together with WHO AFRO and the Global Fund, with support from the SIDA funded 2gether 4 SRHR programme, in early 2021.

Recognizing the persistent and harmful impact that COVID-19 and related lockdown measures pose for the HIV response, governments across ESA region continue to implement interventions to sustain and further advance hard won gains toward ending AIDS. One year after the release of UNICEF's Compendium of innovative approaches to HIV programming in Eastern and Southern Africa in the context of COVID-19, this new Volume II describes results achieved in the nine countries highlighted in Volume I and shares experiences from an additional eight countries. This collective work demonstrates how countries are building upon the learning and architecture of the HIV response to proactively mitigate the impact of the COVID-19 pandemic while scaling up efforts to achieve global HIV goals, resulting in stronger responses and resilient systems for both HIV and COVID-19. Many of the adaptations and innovations described have had a positive impact beyond sustaining HIV services during COVID-19 and are demonstrating exciting opportunities to build back better with more flexible and resilient systems.

This regional report aims to strengthen risk-informed programming and facilitate scale up of simple and effective tools to identify and reach those adolescent girls and young women who are most in need of services and support. All the available tools included in the review are linked in the annexes and included in UNICEF's AGYW Programming and Implementation Repository. 

In the global quest to end the AIDS epidemic as a public health threat by 2030, meeting the HIV-related needs of children, adolescents and pregnant and breastfeeding women represents a critical piece of unfinished business. To inject a sense of urgency in to global efforts to end the epidemic among children, adolescents and young women, global partners joined together in 2015 to launch the Start Free, Stay Free, AIDS Free framework. Unveiled as the global community was embracing a series of 2020 targets intended to Fast-Track the HIV response, Start Free, Stay Free, AIDS Free called for a super-Fast-Track approach to end AIDS as a public health threat among children, adolescents and young women by 2020.

Since the deadline for achieving the targets passed in December 2020, this is the final Start Free, Stay Free, AIDS Free progress report. Although the targets were global, partners identified 23 countries for intensified focus under the framework. This report specifically highlights progress against the targets in focus countries. The only focus countries outside sub-Saharan Africa (India and Indonesia) do not report data on Start Free, Stay Free, AIDS Free targets and are not covered in this report. 

Adolescents in Eastern and Southern Africa (ESA) are key to achieving the global goal of ending the AIDS epidemic by 2030. ESA is home to 1.74 million adolescents living with HIV (ALHIV), representing 60 per cent of this population globally. In 12 ESA countries, AIDS is the leading cause of adolescent mortality. While there is an increasing focus on adolescents, the pace of progress remains slow, especially when compared with the growing needs of ALHIV.

It is time to deliver programmes at scale to address the needs of ALHIV, accelerating evidence of interventions producing results or showing significant promise for scale. This document examines and consolidates the current experiences of ALHIV programming in the region to support further implementation and scale-up of evidence-driven models. The findings serve as a call to action and the key considerations as a guide for governments and funding and implementing partners in scaling up service delivery to ALHIV.

In 2019 it was estimated that 1.2 million children (0-14) were living with HIV in Eastern and Southern Africa, yet more than a half million of these children (504,000) were not receiving lifesaving treatment. Children with HIV need to achieve viral load suppression if they are to lead long and healthy lives. Population-based surveys in Malawi, Uganda and Zimbabwe found that children on treatment fare worse in achieving viral load suppression compared to adults; 42 per cent vs 67 per cent, 39 per cent vs 84 per cent and 47 per cent vs 86 per cent respectively. Ending AIDS will not be possible without accelerating progress for children.

UNICEF, in collaboration with governments and partners, supported a mixed method study that included literature review, assessment of laboratory data in Malawi, Uganda and Zimbabwe and interviews with health workers and caregivers in Malawi to find out what is behind these low rates. The study found that one out of every three children who had a viral load test had not achieved viral load suppression. Support networks for caregivers and children improved adherence and made a difference towards outcome. The full report describes the methodology, key findings, challenges and proposes concrete recommendations to improve treatment outcomes for children with HIV. The accompanying advocacy brief summarizes the key findings and provides action-oriented next steps