quality improvement collaborative to strengthen hiv...
TRANSCRIPT
RESPOND
Quality Improvement Collaborative to Strengthen HIV-Services in the Dnipropetrovsk Region, UkraineRegional Cross-Sectional HIV Service Cascade (2015, 2016, and 2017)
31 930
23 211
17 522
9 047
33 680
24 313
18 621
10 276
2 610
37 400
25 614
19 478
12 626
5 729
28 73725 863
23 277
30 31227 281
24 553
33 66030 294
27 265
0
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25 000
30 000
35 000
40 000
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5 000
10 000
15 000
20 000
25 000
30 000
35 000
40 000
Estimated numberof PLHIV (SPECTRUM)
Officially registered On active follow-up: 1≤ visit per year
On ART VL<1000 copies/mL
as of Jan 1, 2015 as of Jan 1, 2016 as of Jan 1, 2017
90% of PLHIVknow their HIV-status
90% of PLHIV who know their HIV-status,
are on ART
90% of PLHIVwho receive ART,
have undetectible VL
73%
39%
72%
42%
25%
68%
49%
45%н/д
© Public Health Center of MOH of Ukraine; USAID RESPOND, 2017
Progress against UNAIDS '90-90-90' targets, 2015-2017 Dnipropetrovsk region
75% 77%76%
COLLABORATIVE GOAL To strengthen the continuum of HIV prevention, testing, linkage, care and treatment services for PLHIVObjectives• Increase to 90% the proportion of PLHIV who know their status • Increase the proportion of PLHIV in active follow up• Increase to 90% the treatment coverage for PLHIV • Increase to 90% the proportion of PLHIV on ART with undetectable viral load
Collaborative Scale:• 39 QI sites out of the total 40 ART sites in the
region• Six NGO partners: ‘Network 100% of Life’ (Dnipro
and Kryvyi Rih branches), ‘Tsentr Pidtrymky Simyi’, ‘Alliance.Global’, AIDS Healthcare Foundation (AHF) and The Clinton Foundation
• Implementation Period: January 2016 – September 2017
HIV TESTING GAPReasons for the Gap:• Poor quality of pre-test counseling• Lack of motivation for physicians to provide HTS• Lack of information on HTS sites available for patients• Poor awareness on HIV infection among the general population• PLHIV fear of the status disclosure
QI Changes:• HIV testing with two rapid tests or ELISA by specialty physicians and/or PHC
providers • Make HTS info materials available for physicians and patients • Implement a patient tracking system (vouchers, coupons or invitations)• Provide escorting to patients by medical staff • HTS for sexual partners of PLHIV
NGO Interventions:• NGO ‘Network 100% of Life’ (Dnipro branch) • ‘PWID Sexual Partner Health’ – NGO ‘Tsentr Pidtrymky Simyi’• ‘Reach–Test–Treat intervention: model for enrolling MSM to HIV services’ –
NGO ‘Alliance.Global’• Supplies of HIV rapid tests for ART sites, specialty healthcare facilities and
PHC centers – AHF and The Clinton Foundation
SUCCESSFUL QI CHANGES IN HIV TESTINGHIV TESTING WITH TWO RAPID TESTS OR ELISA BY SPECIALTY PHYSICIANS AND/OR PHC PROVIDERSActivities:• Training for specialty physicians on risk behavior and clinical indications
screening, HCT, using of rapid tests and ELISA• Providing specialty physicians with HIV rapid tests• Advocating the rapid test procurements by PHC centers from local budgets• Developing/updating local protocols and patient pathways outlining the role
of PHC providers and specialty physicians in providing HTS
19116 17799 19289 1956822135 22543 21584
25216 24395 25356
1,6% 1,7% 2,0% 2,2% 2,0% 2,2%2,9%
4,1% 3,9% 3,7%
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
0
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15000
20000
25000
30000
Jan-Mar2015
Apr-Jun2015
Jul-Sep2015
Oct-Dec2015
Jan-Mar2016
Apr-Jun2016
Jul-Sep2016
Oct-Dec2016
Jan-Mar2017
Apr-Jun2017
Number of the HIV screening cases made by specialty physicians and the HIV detection rate, Dnipropetrovsk region, 2015 - 2017
Number of people tested for HIV by specialty physicians HIV detection rate
QI
19116 17799 19289 1956822135 22543 21584
25216 24395 25356
1,6% 1,7% 2,0% 2,2% 2,0% 2,2%2,9%
4,1% 3,9% 3,7%
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
0
5000
10000
15000
20000
25000
30000
Jan-Mar2015
Apr-Jun2015
Jul-Sep2015
Oct-Dec2015
Jan-Mar2016
Apr-Jun2016
Jul-Sep2016
Oct-Dec2016
Jan-Mar2017
Apr-Jun2017
Number of the HIV screening cases made by specialty physicians and the HIV detection rate, Dnipropetrovsk region, 2015 - 2017
Number of people tested for HIV by specialty physicians HIV detection rate
QI
HTS FOR SEXUAL PARTNERS OF PLHIV Activities:• Together with NGOs, analyzing the PLHIV register to identify those whose sexual
partners have not received HTS• Motivational counseling for PLHIV to bring their sexual partners for HTS to the
ART site• HTS for PLHIV sexual partners • Analysis of the number of PLHIV sexual partners identified, linked to care and
put on ART
145
197179
277
17 1123
53
12%
6%
13%
19%
0
50
100
150
200
250
300
2013 2014 2015 2016
Number of PLHIV sexual partners tested for HIV, tested positive, and the detection rate,
Dnipropetrovsk region, 39 ART sites, 2013 - 2016
Number of HIV testing cases among PLHIV sexual partners
Number of tested positive for HIV
HIV detection rate
IMPACT OF THE HIV TESTING CHANGES AT THE REGIONAL LEVEL
144
557 538479
442 414
566667 646
568 620509
1,5%
6,7% 6,3% 5,4% 5,2% 5,6% 6,9% 7,2% 6,7% 7,0% 7,5%6% 6%
0,0%5,0%10,0%15,0%20,0%25,0%30,0%35,0%40,0%45,0%50,0%
0
100
200
300
400
500
600
700
800
Jan-Mar 2015
Apr-Jun 2015
Jul-Sep 2015
Oct-Dec 2015
Jan-Mar 2016
Apr-Jun 2016
Jul-Sep 2016
Oct-Dec 2016
Jan-Mar 2017
Apr-Jun 2017
Jul-Sep 2017
Number of people tested positive Number tested positive, 2015 median Testing yield, % Detection rate, 2015 median
HIV Detection: number and proportion tested positive, 2015–2017 Dnipropetrovsk region,39 QI sitesQI
LINKAGE TO CARE GAPReasons for the Gap:
• Poor quality of referrals of PLHIV from NGOs to infectious disease doctors
• Insufficient involvement of social workers in providing social support services
• Patients’ lack of motivation for treatment
• Patients lack funds for transport expenses to visit the AIDS center, for additional lab tests and treatment
QI Changes:
• Return lab results (CD4 and viral load) to ART sites through the Internet• Provide reminder text messages, phone calls or letters to patients• Provide active home visits by medical and social service providers• Register newly detected in-patient PLHIV with AIDS service before they are discharged from
the hospital
NGO Interventions:
• ‘Strengthening the Continuum of HIV Services at ART Sites’ – NGO ‘Network 100% of Life’ (Dnipro branch)
• ‘TB is Curable’ – NGO ‘Network 100% of Life’ (Kryvyi Rih branch)
SUCCESSFUL QI CHANGES IN LINKAGE TO CAREREGISTER IN-PATIENT PLHIV WITH AIDS SERVICE BEFORE THEY ARE DISCHARGED FROM THE HOSPITAL Activities:• In-patients tested positive for HIV sign written consent for transfer of their contact information
to the AIDS service• Hospitals develop procedures for linking to care identified in-patient PLHIV• Transfer of patient contact information to ART site at place of residence• Introducing infectious disease doctor positions in TB and narcological hospitals
3942
3035
42
2328
4753
32
22
33 32
4145
2834
31 29
0 315
20
34
1925
45 48
30
20
31 30
3841
2632
29 28
0%7%
50%
57%
81% 83%89%
96%91% 94% 92% 93% 94%
91% 92% 94% 93% 94% 95%
0%
20%
40%
60%
80%
100%
0
10
20
30
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50
60
70
Jan2016
Feb2016
Mar2016
Apr2016
May2016
Jun2016
Jul2016
Aug2016
Sep2016
Oct2016
Nov2016
Dec2016
Jan2017
Feb2017
Mar2017
Apr2017
May2017
Jun2017
Jul2017
Number and proportion of PLHIV identified during the hospitalization and whose information had been transferred to local ART sites,
Dnipropetrovsk region, 2016 - 2017
Number of people tested positive for HIV during the hospitalization
Number of cases transferring information of PLHIv aidntified to local ATR sites
Proportion of PLHIV whose information had been transferred to local ART sites
SIGNING WRITTEN CONSENT FOR SOCIAL SUPPORT DURING HIV TESTINGActivities:• Signing agreement on social support services for PLHIV between NGO and healthcare
facilities• Edit the text of informed consent for HTS to allow transfer of patient information and social
support• PLHIV sign written consent for social support together with consent for HIV testing (If tested
with ELISA) or after positive test result (if tested with two rapid tests)• If a PLHIV does not receive the test result or if does not visit ART site/Trust Office, then his\
her contact information is transferred to NGO social worker to find this PLHIV for linkage to care
65%59% 58% 60%
79% 75%73% 68% 67%
43%53%
58%50%
56%64%
84%89% 87%
0%
20%
40%
60%
80%
100%
Jan-Mar2015
Apr-Jun2015
Jul-Sep2015
Oct-Dec2015
Jan-Mar2016
Apr-Jun2016
Jul-Sep2016
Oct-Dec2016
Jan-Mar2017
Introducing the written consent for social support while testing for HIV at the Kryvyi Rih PHC Center, Dnipropetrovsk region, 2015 - 2017
Proportion of PLHIV registered with AIDS service without signing consent for social support
Proportion of PLHIV registered with AIDS service with signing consent for social support
IMPACT OF THE LINKAGE TO CARE CHANGES AT THE REGIONAL LEVEL
329
555 758641
496 454
563
1015
816681
752598 598
0
200
400
600
800
1000
1200
Jan-Mar 2015
Apr-Jun 2015
Jul-Sep 2015
Oct-Dec 2015
Jan-Mar 2016
Apr-Jun 2016
Jul-Sep 2016
Oct-Dec 2016
Jan-Mar 2017
Apr-Jun 2017
Jul-Sep 2017
Number of PLHIV registered with AIDS services Number registered, 2015 median
Registration with AIDS service, 2015–2017
QI
Dnipropetrovsk region,39 QI sites
TREATMENT GAPReasons for the Gap:• Excessive workload on ART site physicians
• Long waiting lines for the patients at three ART sites
• Remoteness of ART sites from patient places of residence
• Lack of capacities to initiate more patients on ART at three ART sites (workload is up to 1,050 patients per one doctor)
QI Changes:
• Transfer ART patients from AIDS Centers to local ART sites
• ART dispensing by a PHC medical provider at the district level
• Manage ART stock at ART site
• Assessment of ART adherence by physician at every patient visit (quality assurance)
NGO Intervention:
• ‘Strengthening the Continuum of HIV Services at ART Sites’ – NGO ‘Network 100% of Life’ (Dnipro branch)
SUCCESSFUL QI CHANGES IN TREATMENT
TRANSFER ART PATIENTS FROM AIDS CENTERS TO LOCAL ART SITESActivities:• Analyzing the patient register at the regional AIDS Center and identifying those who
may be transferred to local ART sites• New ART sites opened• Preparing documentation to transfer ART patients to local ART sites• Transferring ART patients to local ART sites
133 147 158
301356 405 447 494 516 543 563 583
133 147 158 171237 271 305 335
390 395 412 433
100% 100% 100%
57%67% 67% 68% 68%
76% 73% 73% 74%
0
100
200
300
400
500
600
700
Number and proportion of PLHIV on ART, Kryvyi Rih STI hospital, Dnipropetrovsk region, 2016
Number of PLHIV registered with AIDS service Number of PLHIV on ART Proportion of registered PLHIV on ART
IMPACT OF THE TREATMENT CHANGES AT THE REGIONAL LEVEL
473602 604
653 623 680
879
1152
1369
941
690603 603
0
200
400
600
800
1000
1200
1400
1600
Jan-Mar 2015
Apr-Jun 2015
Jul-Sep 2015
Oct-Dec 2015
Jan-Mar 2016
Apr-Jun 2016
Jul-Sep 2016
Oct-Dec 2016
Jan-Mar 2017
Apr-Jun 2017
Jul-Sep 2017
Number of PLHIV initiated on ART Number initiated on ART, 2015 median
Initiation on ART, 2015–2017
QI
Dnipropetrovsk region,39 QI sites
PATIENT SURVEY RESULTS FROM THE 39 ART SITES IN THE DNIPROPETROVSK REGION, JANUARY 2016 (640 PEOPLE)
AND JULY 2017 (687 PEOPLE)
Proportion among patients tested for HIV in the last 6 months (%), Dnipropetrovsk region
84,4
81,2
88,6
63,9
98,2
97,6
86,6
67,3
66,9
73,9
34
96,9
95,8
78,6
I received test on HIV in the day of the first visit (p<0.001)
I received test at a conveniently located health facility, (p<0.001)
I received test at the convinient time, (p<0.001)
I received HIV test results in the day of testing, (p<0.001)
I received clear explanation of HIV test results
I received clear advice regarding the next steps
I received test at a conveniently located health facility, (p<0.001)
Round 1 Round 2
What you do not like about the services of this health facility, Dnipropetrovsk region, % among all respondents
3,3
7,7
2,3
5,2
26,8
1,5
16,9
15,2
14,8
11,9
10,6
39,2
4,7
8,8
Doctor's working hours, p<0.001
Laboratory working hours, p<0.001
Mismatching of doctor's and laboratory hours, p<0.001
Waiting time for test results, p<0.001
Waiting time at doctor's office (lines), p<0.001
Medical staff attitude, p<0.001
Service fees, p<0.001
Round 1 Round 2
ACHIEVEMENTS
•Practice of PLHIV in-patients’ registration with AIDS service before they are discharged from the hospital became a routine practice at the AIDS and TB service
•Specialty physicians (TB, narcology, STI, neuropathology, oncology, and others) actively involved to providing HTS
•Rapid tests purchased from PHC facilities budget
• Involving other healthcare services (therapy, neurology, oncology, and pulmonology) to registration of in-patients with AIDS service before discharge
•Decentralizing HIV services – transfer of ART patients from the AIDS centers to local ART sites. Decreased workload of AIDS center physicians
CHALLENGES
• Decreased initiation on ART and returning of patients lost to follow up back to care after reaching PEPFAR targets for HIV treatment
• Dependence of health care facilitates on rapid test supplies by international donors; procurements from local budgets do not cover the needs in full
• Delays in ARVs supplies
• Some patients do not want to receive ART at their places of residence
NEXT STEPS
• Signing QI Charter – 2020• Introduce the most effective QI changes into routine practice• Further control over procurement and using of the HIV rapid tests at PHC
facilities• Training on HTS with rapid tests for family doctors• Systematic monitoring of the ART stock •Cooperation with NGOs to improve linkage to care
385 381 324 259 219 218 183 163
280 276 241 189 160 158 121 102
414 409 372284 253 248 199 152
513 510 477388 361 343
258 208
569 551516
417 393 360183 151
508 489467
360350
614 520511
263262
0
3283 31362908
2160 1998
1327944 776
Cohort:ELISA at
registration
Registered withAIDS service
Remainregistered
on reportingdate
Enrolled on ART Remainon ART
on reportingdate
Remain on ART 6≤ months
Viral load testwithin last 6
months
Viral load <40copies/ml
Jan 2016 - Sep 2017 Cohort cascade as of October 1, 2017 Jan-Mar 2016 cohortApr-June 2016 cohortJul-Sept 2016 cohortOct-Dec 2016 cohortJan-Mar 2017 cohortApr-June 2017 cohortJul-Sept 2017 cohort
Dnipropetrovsk region, 31 QI sites
147 910
168
82%
69%96%
© USAID RESPOND Project, 2017 © Проект USAID RESPOND, 2017 © Pact, Inc., 2017